INFORMED CONSENT TO PARTICIPATE IN A RESEARCH PROJECT

INTRODUCTION
This form asks for your agreement to participate in a research project on the role of mental wellness on attrition and retention in engineering programs. Your participation involves the completion of this survey. It is expected that your participation will take approximately 10 minutes. There are some potential risks associated with this project. You and others may benefit indirectly from your participation. If you are interested in participating, please review the following information.

PURPOSE OF THE STUDY AND PROPOSED BENEFITS
· The purpose of the study is to determine whether there is a link between mental wellness and success in engineering programs.

· The results of this survey will be used to develop research-based interventions and training materials that programs like yours to improve wellness of engineering students in your institution.

YOUR PARTICIPATION
· If you agree to participate, you will be asked to complete the following survey.

· Your participation will take approximately 10 minutes.

PROTECTIONS AND POTENTIAL RISKS
· Please be aware that you are not required to participate in this research, refusal to participate will not involve any penalty or loss of benefits to which you are otherwise entitled, and you may discontinue your participation at any time. The survey will require you to answer all of the questions but you can select “prefer not to answer” or choose to discontinue your participation at any time.

· There are some risks anticipated with your participation in this study. The surveys will ask about your mental health. The researchers are mandatory reporters and are required to make reports of persons who might harm themselves or others. If you should experience any emotional distress when answering any of these questions or would like to explore your own mental wellness in more depth, please get in touch with Cal Poly’s counseling center at 805-756-2511.

· Your confidentiality, should you choose to provide an email address to be contacted for future surveys, will be protected in HIPAA compliant storage and all personally identifying information will be securely deleted at the conclusion of the study. The researchers will be required to break confidentiality should you provide information that invokes mandatory reporting laws.

· Identifying information might be removed from identifiable private data and that, after such removal, the information could be used for future research studies or distributed to another researcher for future studies without additional informed consent.

RESOURCES AND CONTACT INFORMATION

· If you should experience any negative outcomes from this research, please be aware that you may contact Cal Poly’s counseling center at 805-756-2511, for assistance.

· This research is being conducted by Andrew Danowitz in the Department of Electrical Engineering and Geneva Reynaga-Abiko of Counseling Services at Cal Poly San Luis Obispo, as well as Kacey Beddoes with the SJSU College of Engineering Dean's Office and Research Foundation. If you have questions regarding this study or would like to be informed of the results when the study is completed, please contact the researcher at adanowit@calpoly.edu.

· If you have concerns regarding the manner in which the study is conducted, you may contact Dr. Michael Black, Chair of the Cal Poly Institutional Review Board, at (805) 756-2894, mblack@calpoly.edu, or Ms. Trish Brock, Director of Research Compliance, at (805) 756-1450 or pbrock@calpoly.edu.

AGREEMENT TO PARTICIPATE
If you agree to voluntarily participate in this research project as described, please indicate your agreement by clicking “I agree to participate below.” Please retain a copy of this form for your reference, and thank you for consideration.

Question Title

* If you agree to voluntarily participate in this research project as described, please indicate your agreement by selecting “Yes, I volunteer” below.  Please print (or save a pdf of) this consent form for your reference. Thank you for your participation.

 
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