First Name
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Last Name
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Please provide your email address:
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Please provide your phone number:
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Are you a parent answering questions for your child?
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Yes
No
How did you hear about us?
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Social Media
YMCA
UT Dallas
Coffee Shop
Through a Friend
Other
If other, please specify:
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How old are you?
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Child's Name
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What is your child's age?
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Are you and your child interested in participating in the study?
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Yes
No
Are you interested in participating in the study?
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Yes
No
CONSENT TO PARTICIPATE IN SCREENING PROCEDURE OF RESEARCHDevelopment of Self and Social Processing in Adolescence (UTD IRB: IRB-23-341) Alva Tang Contact Number: 972-883-382
You are providing information to questions that will determine your own eligibility (if you are over age 18) or your child's eligibility (if you are a parent) for a research study. This consent form will help you choose whether you will provide information in this initial screening process. To determine your own eligibility or your child's eligibility (if you are a parent) for a study examining how adolescents' brains interact with and process social media content. We will ask you several questions about your child. The question will ask about demographics (e.g., age), history of head trauma, and neurological disorders.
If you or your child are eligible to participate in the actual study, you will be one of approximately 100 people in this research study. The screening questions will take less than 5 minutes to complete. There is minimal risk associated with participation in this study. The questions include information about demographic and health information. You may not directly benefit from this screening procedure of this study, but others may benefit by applying the knowledge from the data gathered to design further prevention and intervention studies. You may choose not to participate in this screening procedure. Participation is voluntary. All individuals have the right to agree or refuse to participate in this screening process. Individuals who consent to participate also have the right to change their minds at any time during the procedure by not submitting the information online or by telling the researcher that you no longer wish to be included. Refusal to participate will not affect your legal rights or the quality of healthcare and education you may wish to receive at any healthcare setting or higher education institution. Your participation (or decision not to participate) will not affect your grades or education in any way. All of the information participants provide to investigators as part of this research will be protected and held in confidence within the limits of the law and institutional regulation. All electronic data will be kept on password protected computers on a server that can only be accessed by the Laboratory for Healthy Socio-emotional Development staff and graduate students. The key file that links directly identifying information (name and contact information) to the code will be stored in a password-protected file on a secure computer network. If a subject is eligible and has agreed to be contacted for follow-up studies, the key file will include the link between name, contact information, and study code. Only trained research personnel within the lab, who are working on the study will have access to the data. Collaborators who work on the study will only have access to deidentified data. Members and associated staff of the IRB of the University of Texas at Dallas may review the records of your participation in this research. An IRB is a group of people who are responsible for assuring the community that the rights of participants in research are respected. A representative of the UTD IRB may contact you to gather information about your participation in this research. If you wish, you may refuse to answer questions the representative of the IRB may ask. The results of this research may appear in publications but individual participants will not be identified. If you want more information about this research, contact the researchers listed on the first page of this form. Participants who want more information about their rights as a participant or who want to report a research related injury may contact:
CONSENT TO PARTICIPATE IN SCREENING PROCEDURE OF RESEARCHDevelopment of Self and Social Processing in Adolescence (UTD IRB: IRB-23-573) Alva Tang 972-883-382
You are providing information to questions that will determine your own eligibility (if you are over age 18) or your child's eligibility (if you are a parent) for a research study. This consent form will help you choose whether you will provide information in this initial screening process. To determine your own eligibility or your child's eligibility (if you are a parent) for a study examining brain processes during social evaluation and relations with behavior in adolescence. We will ask you several questions about yourself (if you are over age 18 and interested in participating) or about your child (if you are a parent interested in participating with your child). The question will ask about demographics (e.g., age), history of head trauma, and neurological disorders. If you or your child are eligible to participate in the actual study, you will be one of approximately 100 people in this research study. The screening questions will take less than 5 minutes to complete. There is minimal risk associated with participation in this study. The questions include information about demographic and health information. You may not directly benefit from this screening procedure of this study, but others may benefit by applying the knowledge from the data gathered to design further prevention and intervention studies. You may choose not to participate in this screening procedure. Participation is voluntary. All individuals have the right to agree or refuse to participate in this screening process. Individuals who consent to participate also have the right to change their minds at any time during the procedure by not submitting the information online or by telling the researcher that you no longer wish to be included. Refusal to participate will not affect your legal rights or the quality of healthcare and education you may wish to receive at any healthcare setting or higher education institution. Your participation (or decision not to participate) will not affect your grades or education in any way. All of the information participants provide to investigators as part of this research will be protected and held in confidence within the limits of the law and institutional regulation. All electronic data will be kept on password protected computers on a server that can only be accessed by the Laboratory for Healthy Socio-emotional Development staff and graduate students. The key file that links directly identifying information (name and contact information) to the code will be stored in a password-protected file on a secure computer network. If a subject is eligible and has agreed to be contacted for follow-up studies, the key file will include the link between name, contact information, and study code. Only trained research personnel within the lab, who are working on the study will have access to the data. Collaborators who work on the study will only have access to deidentified data. Members and associated staff of the IRB of the University of Texas at Dallas may review the records of your participation in this research. An IRB is a group of people who are responsible for assuring the community that the rights of participants in research are respected. A representative of the UTD IRB may contact you to gather information about your participation in this research. If you wish, you may refuse to answer questions the representative of the IRB may ask. The results of this research may appear in publications but individual participants will not be identified. If you want more information about this research, contact the researchers listed on the first page of this form. Participants who want more information about their rights as a participant or who want to report a research related injury may contact:
Please enter your parents first and last name.
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Please enter your parents email.
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Please enter your parents phone number.
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SignaturesA participant's signature indicates that they have read, or listened to, the information provided above and that they have received answers to their questions. The signature also indicates that they have freely decided to participate in this research procedure and that they know they have not given up any of their legal rights.
If you agree to the above, please sign:
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Name of Signature
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Today M-D-Y
Answering for child:
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Yes
No
Does your child use Instagram reels?
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Yes
No
Does your child use YouTube shorts?
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Yes
No
Does your child have a history of head trauma and/or seizures that have led to loss of consciousness?
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Yes
No
Does your child have any neurological disorders (e.g., epilepsy, encephalitis)?
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Yes
No
Does your child have any neurosensory disorders? (e.g., deaf and hard of hearing, vision, intellectual disabilities)
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Yes
No
Does your child currently use psychotropic medications (e.g. anti-depressants, anxiolytics, anti-psychotics) or stimulants (e.g., for ADHD)
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Yes
No
If yes, what kinds of psychotropic medications? (please list)
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Does your child have a hairtype (e.g., braids, fake hair) that would make it difficult to put a swim cap on?
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Yes
No
Are you willing to take out these braids and fake hair for the experiment so that we can place an EEG net on the head to measure brain activity?
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Yes
No
Is your child allergic to soap or latex?
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Yes
No
Does your child have his/her own smart mobile phone?
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Yes
No
Participating in Future Research Studies: We would like to contact you in the future to see if you would be interested in participating in a research study. Please indicate below if you are willing to be contacted about any future research studies.
Yes, I agree to be contacted about future research studies
No, I do not want to be contacted about future research studies
If you are eligible, you will receive an email with an invitation code to sign up on SONA (if you are a UTD student) or we will give you a phone call.
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