Gender:

Male | Female

Name:

Do not use home phone or address if at all avoidable.

University Phone Number (please format, e.g. (212) 998-4808 or +44 (20) 7839 8040):

University/Mailing Address:

Email Address:

NYU School (if applicable):
College of Dentistry Courant Institute of Mathematical Sciences Division of Libraries Ehrenkranz School of Social Work Faculty of Arts & Science Gallatin School of Individualized Study Institute of Fine Arts School of Continuing & Professional Studies School of Law School of Medicine Steinhardt School of Education Stern School of Business Tisch School of the Arts Wagner Graduate School of Public Service

NYU Department (if applicable):

Institution (if non-NYU):

Faculty Sponsor Name:

Faculty Sponsor Phone Number (please format, e.g. (212) 998-4808 or +44 (20) 7839 8040):

Faculty Sponsor Email Address:

University/Mailing Address:

Faculty Sponsor School (if applicable):
College of Dentistry Courant Institute of Mathematical Sciences Division of Libraries Ehrenkranz School of Social Work Faculty of Arts & Science Gallatin School of Individualized Study Institute of Fine Arts School of Continuing & Professional Studies School of Law School of Medicine Steinhardt School of Education Stern School of Business Tisch School of the Arts Wagner Graduate School of Public Service

Faculty Sponsor Department (if applicable):

Faculty Sponsor Institution (if non-NYU):

Type of Research:

Doctoral dissertation | Master's thesis

class project | faculty-directed research

Other (please specify, e.g. independent study, undergraduate honors thesis):

Purpose of the Study:

You have been invited to take part in a research study to learn more about

Example 1: the effect of time of day on reading comprehesion.

Example 2: whether people make economic decisions differently when working in a group versus individually.

Example 3: how viewing pictures of natural disasters effects fear of terrorism.

Description of Procedures:

If you agree to be in this study, you will be asked to do the following:

1.
2.
3.
4.
5.

Example 1: Complete a questionnaire about your background (age, gender, education, etc.).

Example 2: Take part in an interview about your responses to two videos showing different hiring techniques for a job as a personnel director.

Example 3: Play three rounds of a computer game that asks you to be an auction buyer in competition with other buyers for a work of art.

If you need more than 5 items, add them manually in your word processing program once the draft has been generated.

Length of Participation (total number & approximate length of sessions):

Participation in this study will take

Example: two hours of your time: 30 minutes to complete the questionnaire and approximately 45 minutes for each of the two interviews. The interviews will be held two weeks apart.

Session Recording (will the subject be audio/video-taped?):

None | Audio | Video

Risks & Assistance Available (is there more than minimal risk, i.e., beyond those of everyday life?):

Yes | No

If Yes, please describe:

Example 1: Although every effort will be made to prevent it, you may find the sensitive nature of some of the questions upsetting. In that event, the investigator will provide you with a referral to a counselor with whom you may discuss your feelings.

Example 2: There is a risk that you may have some muscle soreness for about four days.

Physical Injury (is there more than minimal risk and any possibility of physical injury?):

Yes | No

Fees or Incentives (is there payment, travel reinbursement, gift certificates, etc?):

Yes | No

If Yes, please describe:

Example 1: You will be paid $50 dollars for completing both interview sessions; if you withdraw before the end of the study, no payment will be given.

Example 2: You will receive 1 hour of credit towards your course requirement for completing both surveys; if you withdraw before the end of the study, no credit will be given.

Example 3: You will be paid $30 dollars at the end of each session; if you withdraw before the end of the study, you will keep the payment received for completed sessions.

Methods to Protect Confidentiality:

Confidentiality of your research records will be maintained by

Example 1: assigning code numbers to each participant so that data is never directly linked to individual identity.

Example 2: keeping all completed forms in a locked cabinet only accessible to the investigator.

Example 3: submitting forms with no identifiers to a sealed drop box so that subjects are anonymous.

Minors Involved (< 18 years of age):

Yes | No

Focus Groups or Other Group Activities:

Yes | No

Quotes (will you quote subjects by name?):

Yes | No

Nonparticipation or Withdrawal (only applicable if subjects are student or receive service from a related agency/organization):

Nonparticipation or withdrawal

Example 1: will not affect your services you receive at the NYU Medical Center.

Example 2: will not affect your grades or academic standing.