ADULT CONSENT FORM
Princeton University

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TITLE OF RESEARCH: Screening survey for: "Behavioral study to predict the efficacy of a self-help tool"
PRINCIPAL INVESTIGATOR: Professor Yael Niv, Ph.D.
PRINCIPAL INVESTIGATOR’S DEPARTMENT: Princeton Neuroscience Institute

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Key information about the survey:

You are about to complete a screening survey for the study named “Behavioral study to predict the efficacy of a self-help tool”. In order to participate in the screening, your informed consent is being sought. Participation in this survey is voluntary.

Purpose of the survey:

The purpose of the survey is to determine if our study, "Behavioral study to predict the efficacy of a self-help tool", is right for you.

Expected duration of participation:

3 minutes

The procedures that you will be asked to follow in the research:

In this survey, you will be asked to answer questions.

This survey includes questions related to mental health: about your emotions and reactions to being placed in certain situations, and the levels at which you may identify with certain thoughts or feelings. Some participants may find these questions troubling.

Examples of such questions are:

• Over the last 2 weeks, how often have you felt nervous, anxious, or on edge?
• Have you become sad, depressed or irritable for several days or more without really understanding why?

If any of the questions trouble you, we urge you to seek further advice or information from healthcare professionals. (Please note that the experimenters are not in a position to make any diagnoses or offer medical advice.) At the end of the experiment, we will provide you with resources for learning more about mental health conditions and for seeking support.

The benefits to you or to others, e.g., society that may reasonably be expected from the research:

We may determine that our study, "Behavioral study to predict the efficacy of a self-help tool", is right for you and invite you to participate in that study.

The alternative procedures, if any, that might be advantageous to participants:

None

Additional information about the survey:

Confidentiality:

All data collected from this survey will be kept confidential. Your data will be stored on password-protected servers. The research team will be the only party that will have access to your data. We will not share your data with anybody. Your information collected as part of the research, even if identifiers are removed, will not be used or distributed for future research studies without your explicit consent.

Note that if we find that our "Behavioral study to predict the efficacy of a self-help tool" is right for you, we will use the email you provided to invite you to the study, using a commercial email software. In that case, you will receive a new consent form that describes all parts of the "Behavioral study to predict the efficacy of a self-help tool" and how the collected data is used. If you consent to participate in our "Behavioral study to predict the efficacy of a self-help tool", we will use your responses from this screening survey as part of the "Behavioral study to predict the efficacy of a self-help tool".

This research is covered by a Certificate of Confidentiality from the NIH. Researchers with this Certificate will not disclose or use information that may identify you in any federal, state, or local civil, criminal, administrative, legislative, or other action, suit, or proceeding, even if there is a court subpoena. Exceptions include: a) A federal, state, or local law that requires disclosure, such as reasonable cause to believe that a child has been subjected to child abuse or acts of child abuse. b) Your explicit approval for the researchers to release your name and/or personally identifiable information.

Compensation:

You will not be compensated for participation in the screening survey.

Who to contact with questions:

1. Principal investigator:

• Yael Niv, Ph.D.
• Princeton University
• Email: yael@princeton.edu

2. Study team:

• Niv Leap Study Team
• Princeton University
• Email: nivleap@princeton.edu

If you have questions regarding your rights as a research subject, or if problems arise which you do not feel you can discuss with the Investigator, please contact the Institutional Review Board at:

• Phone: (609) 258-8543
• Email: irb@princeton.edu

If you wish to save a copy of this consent form, click the Print button to print and/or save as PDF:

Print or Save Consent Form

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Summary:

I understand the information that was presented and that:

• My participation is voluntary.
• Refusal to participate will involve no penalty or loss of benefits to which I am otherwise entitled.
• I may discontinue participation at any time without penalty or loss of benefits.
• I do not waive any legal rights or release Princeton University or its agents from liability for negligence.
• I must provide a working email address and that email address will be used by the researchers to communicate with me about the survey and study.

By clicking the box below, I hereby give my consent to be the subject of your research.

Would you like to be re-contacted for future studies?

Yes No

I accept No thank you