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Statement of Informed Consent, please read carefully:

Title of Project: Cognition and Student Health

Principal Investigator: Rachael Huck

You are being asked to participate in a project conducted through Maryville University by Rachael Huck, an undergraduate student at Maryville University working under the direction of her faculty advisors: Dr. Brian Bergstrom, Assistant Professor of Psychology, and Dr. Peter Green, Associate Professor of Psychology and Senior Seminar instructor. The University requires everyone who agrees to participate in this project to provide signed consent to do so.

The overall purpose of this research is to explore the relationship between certain aspects of student cognition and student health. Your participation will involve the completion of five brief surveys as well as a demographic questionnaire. Your participation will take approximately 30 minutes.

This study may include some risks or discomfort which would involve disinterest, fatigue, or concerns over one’s health. To minimize risks, the research will employ the following safeguards: full debriefing as well as information regarding campus health services. Moreover, anonymity is ensured by not requiring participants to share identifying information; if participants choose to share identifying information, it will have no connection to any survey responses.

All collected data will be retrieved and maintained by the faculty advisor (Dr. Brian Bergstrom) and stored exclusively under password protection of the faculty advisor. The results of this study may be presented in academic settings and/or published in scientific journals, but participants’ identities and individual data will not be revealed in any presentation or publication that may result from this study. All data will be destroyed two years after the final presentation or publication.

Your participation is entirely voluntary and you may choose not to participate in this study or to withdraw your consent at any time. You will not be penalized in any way should you choose to withdraw or to not participate.

We do not promise you will receive benefits from this study, but the information gathered through this study may advance our general scientific understanding of human cognition and student health, and in that way facilitate our understanding of how to improve student health.

There is a chance that you will be compensated for your time: at the end of the surveys, you will have the option be entered into a drawing for one of four $25 gift cards to Following the surveys, you will be given the chance to provide your name and email address. If you would like to be entered into the drawing, you may provide this information. If you would not like to enter the drawing or are uncomfortable sharing this information, you may leave the section blank. In any case, rest assured that any identifying information you provide will remain confidential and will not be connected to your survey responses. At the end of the data collection period, four participants who have provided their names and email addresses will be randomly selected to receive the gift cards; these recipients will be notified at the time of the drawing.

If you have any questions regarding this study, or if any problems arise, you may email the researcher, Rachael Huck, at You may also contact the researcher’s faculty advisor, Dr. Brian Bergstrom, at or at (314) 529-9250. You may also ask questions, state concerns regarding your rights as a research subject, or express any feelings of pressure to participate by contacting: Dr. Robert Bertolino, Chair of the Institutional Review Board at Maryville University, (314) 529-9659.

Maryville University recognizes its federally mandated responsibility to ensure that research be conducted in an ethical and scholarly manner, respecting the rights and welfare of all the human participants.  Any research misconduct including but not limited to fabrication, falsification, or plagiarism in proposing, performing and reviewing research, or in reporting research results, should be reported to Dr. Tammy Gocial, the Research Integrity Officer at Maryville University at (314) 529-6893.

Maryville University investigators, and their colleagues who are conducting research, recognize the importance of your contribution to the research studies which are designed to improve student health.  Maryville University investigators and their staff will make every effort to minimize, control, and treat any complication that may arise as a result of this research.

Advancing to the survey will signify your implied consent to participate. You are agreeing to participate in this study based on the information presented to you.  You may choose to withdraw without prejudice or penalty.  Please print a copy of this form which includes the name and phone number of the researcher and the IRB at Maryville University, should you have any questions.

The date approval stamp on this consent form indicates that the project has been reviewed and approved by the Maryville University Institutional Review Board.

Student Researcher: Rachael Huck
Date: 9/28/2016

Supervising Faculty Member: Dr. Brian Bergstrom
Date: 9/28/2016

Maryville University Institutional Review Board
Protocol Number: 16FA PSYC 480-02-04
Initiation Date: 9/28/16
Termination Date: 9/28/17