Sign-up Sheet for the Research Study
We appreciate your interest in participating in a research study on the long-term effects of PTSD on women. Kindly note that filling this form does not guarantee your participation in the study. If you are eligible for the participation, you will be contacted by our research team where more information regarding the research will be offered
Kindly fill your information accurately
Surname First Name ________________
Age_____________
Mobile Number _______________
Email Address ________________
Have you ever experienced traumatic events as a child?
Signature ______________ Date_____________
Please make sure that the form is returned to the psychiatric office. The confidentiality of your information is ensured. Thank you for your interest in the research study. We appreciate your efforts.
Informed Consent for Study Participation
Researchers: Felisha Farrington, Psychology Student, Wilmington University
Research Assistants (Students), Wilmington University
Study Purpose: This study seeks to examine how traumatic events experienced in childhood affect an individual’s adulthood.
Confidentiality: Personal information regarding the participants will be highly regarded as confidential. The internal Review Board may decide to review the research study, but according to the confines of the board members involved in the review, your information will remain confidential. In case the study is published, your details will not be published.
Study Procedures: Participation in this study will require you to feel the Beck Depression Inventory as well as the Generalized Anxiety Disorder Checklist before engaging in a mental health assessment with our research assistants. Later you will participate in sleep monitoring activity. In case you feel to discontinue the participation at any time, you are permitted to—Incase of clarifications, questions, or any concern you may communicate to any of the researchers.
Possible Risks/ Discomforts: There are no potential risks associated with the study as it only requires filling in in forms, interviews with our assistants, and sleep monitoring where no physical activities are required.
Compensation: 10$ will be awarded to all participants in compensation for the visits and travel time. Advice will also be offered to the participants on how to avoid traumatization and retraumatization.
Researchers Contact Information
Felisha Farrington
I acknowledge that I have read and understood the description and procedures entailed in the study. I am allowed to address any questions or concerns with the researchers participating in the research, and I may discontinue my participation at any time.
Participant’s Signature _____________ Date_________
Researchers Signature ______________ Date__________
Generalized Anxiety Disorder (GAD) Screening Tool
This is a screening measure to help you determine whether you might have Generalized Anxiety Disorder (GAD) that needs professional attention. This screening tool is not designed to make a diagnosis of GAD but to be shared with your primary care physician or mental health professional to inform further conversations about diagnosis and treatment.
Directions:
- Print out the results
- Complete the provided form
- Share them with your health care provider to determine a diagnosis
Are you troubled by the following?
| ☐ Yes ☐ No | Do you experience excessive worry? |
| ☐ Yes ☐ No | Is your worry excessive in intensity, frequency, or amount of distress it causes? |
| ☐ Yes ☐ No | Do you find it difficult to control the worry (or stop worrying) once it starts? |
| ☐ Yes ☐ No | Do you worry excessively or uncontrollably about minor things such as being late for an appointment, minor repairs, homework, etc.? |
| Please list below the most frequent topics about which you worry excessively or uncontrollably.
List most frequent topics about which you worry excessively or uncontrollably here. | |
| ☐ Yes ☐ No | During the last six months, have you been bothered by excessive worries more days than not?
|
During the past six months, have you often been bothered by any of the following symptoms? Check one square next to each symptom that you have had more days than not:
| Not at all | A little | Moderately | Quite a bit | Extremely | |||||
| a. restlessness or feeling keyed up or on edge | | | | | | | | | |
| b. Irritability | | | | | | | | | |
| c. difficulty falling/staying asleep or restless/unsatisfying sleep | | | | | | | | | |
| d. being easily fatigued | | | | | | | | | |
| e. difficulty concentrating or mind going blank | | | | | | | | | |
| f. muscle tension | | | | | | | | |
How much do worry and physical symptoms interfere with your life, work, social activities, family, etc.?
| | | | | | | | | |
| None | Mild | Moderate | Severe | Very Severe |
How much are you bothered by worry and physical symptoms (how much distress does it cause you)?
| | | | | | | | | |
| None | Mild | Moderate | Severe | Very Severe |
Source: Newman, M. G., Zuellig, A. R., Kachin, K. E., Constantino, M. J., Przeworski, A., Erickson, T., & Cashman-McGrath, L. (2002). Preliminary reliability and validity of the Generalized Anxiety Disorder Questionnaire-IV: A revised self-report diagnostic measure of generalized anxiety disorder. Behavior Therapy, 33, 215-233. doi:10.1016/S0005-7894(02)80026-0