Consent Form 

Social Adversity Study

Introduction:  You are invited to participate in a study entitled the Social Adversity Study, which is being conducted by Dr. Marsha Runtz (Associate Professor in the Department of Psychology and Ms. Keara Rodd (master’s student in Clinical Psychology) at the University of Victoria, Victoria, BC, Canada. You may contact Ms. Rodd at 250-472-4177 if you have any questions about this research. You may also contact Dr. Marsha Runtz, the principal investigator, at 250-721-7546 or

Purpose & Importance of the Study:  The purpose of this research is to explore within the general population, different aspects of well-being and to examine the links between various life experiences, discrimination and micro-aggression, and psychological symptoms. This study is important because there is a lack of research in this area and because the findings will provide important information about factors which might influence the development of psychological well-being, as well as more information regarding the impact of discrimination. Understanding how life experiences and discrimination might affect one’s psychological well-being will also provide important information for prevention and treatment of the effects of these experiences as well as to address larger issues of social inequities and discrimination.

Voluntary Participation:  Your participation in this research must be completely voluntary. You may withdraw from the study at any time and you may refuse to answer any question(s) without having to explain your reasons for doing so and without consequences.  If you change your mind about having your responses used in this research or do not want to answer any further questions, please indicate this by continuing to the end of the survey where you will select “I do not wish to submit this survey.” Any of the data you provided will be discarded and you will be forwarded to the final page which contains your unique HIT code so you will still be able to receive compensation. HOWEVER, AFTER SUBMITTING YOUR DATA ONLINE IT WILL BE LOGISTICALLY IMPOSSIBLE TO WITHDRAW (OR TO REMOVE YOUR DATA)

Anonymity:  All of the responses that you give in this study are completely anonymous and confidential; your name will not be linked to your responses in any way. Your answers will be kept in an anonymous data bank without the possibility of identifying you. All of the information collected will be used for group-based analyses; that is, questionnaires will not be analyzed individually but will be pooled together with a large number of responses from other participants. Please do not write in or submit your name in any place on the questionnaire and please do not provide the names of any other individuals that may have been involved in any of the events you disclose in this questionnaire. We are limiting participation in this study to individuals who are 19 years of age or older. If, however, we receive identifying information that leads us to believe that you or any individual who is under 19 years of age is at risk of harm, we would be obliged to inform the proper authorities. If, you would like to report an incident of child maltreatment yourself or if you have concerns about a child at risk of maltreatment, please see the list of numbers at the bottom of this page.
If you choose to submit your email address into the prize draw, you will do this through a separate screen that ensures that your email address cannot be linked to your questionnaire.

The confidentiality of your data will be further protected by keeping your responses and all data files and other research records secure (e.g., in password protected files and computers in locked offices). Only the researcher and research assistants will have access to the data). Computerized anonymous data files will be kept for up to 10 years beyond the date of the last publication of the findings from this study.

Sensitive Topics:  If you decide to participate in this study, you will be asked to complete an online questionnaire that inquires about a range of psychological and social issues that include some personal or sensitive topics such as difficult life experiences such as victimization across the lifespan, discrimination based on gender, race, sexual orientation, or gender identity, as well as psychological well-being, and general demographic information.

Eligibility:  You are eligible to participate in this study if you are 19 years of age or older.

Inconvenience & Risks:  Participation in this study may cause some inconveniences to you, including the time it will take to complete the questionnaire (approximately 30 mins). A potential risk of participating in this research is that some people may feel some emotional discomfort as a result of answering questions of a sensitive nature (e.g., about difficult life experiences). To deal with these risks, we want you to know that you don’t have to answer any questions that make you feel uncomfortable, that you can withdraw your participation at any time, and that you can contact the researcher (Dr. Runtz) or research assistant (Ms. Rodd) about any concerns you might have that have arisen as a result of participating in this research. In addition, phone numbers for support resources will be provided at the end of this letter, should these services be of need to you. 

Benefits:  In addition to compensation provided by the website MTurk, the potential benefits of your participation include: 1) experiencing psychological research methods first hand; 2) helping us, the researchers, to assess the psychometric qualities of a questionnaire evaluating micro-aggressions; and 3) helping us to understand how life experiences (including discrimination) might affect people’s psychological health and well-being.

Compensation:  To compensate you for your participation, you will be offered the opportunity to be entered into a prize draw for 1 of 10 Amazon gift cards (worth $25 each). It is important for you to know that it is unethical to provide undue compensation to research participants, and if you agree to participate in this study, this form of compensation should not be coercive. If you would not participate were this prize draw not offered, then you should decline. If you would like to enter the prize draw, before you exit the survey, you will be see a separate page with a place to enter your email address. YOUR EMAIL ADDRESS WILL BE SENT DIRECTLY TO A SEPARATE EMAIL ACCOUNT SO IT CAN NOT BE LINKED TO YOUR ANSWERS AND ANY IDENTIFYING INFORMATION PROVIDED FOR THE PURPOSE OF THE DRAW WILL BE DESTROYED FOLLOWING THE DRAW AND THE SUCCESSFUL DELIVERY OF THE PRIZES TO THE WINNERS.

Results from the Study:  After you have completed the study, you will receive a debriefing form that outlines the basic purpose of the research in more detail. If you would like a summary of the findings after the study is completed, you can contact Dr. Runtz directly, or check her website (at for summaries of papers prepared from this and related projects. It is anticipated that overall findings from this study will be shared with others in the following ways: in presentations to other graduate students and faculty, in conference presentations, on the website, and in published articles.

Ethical Approval:  In addition to being able to contact the researchers, you may verify the ethical approval of this study, or raise any concerns you might have by contacting the Human Research Ethics Board at the University of Victoria at (250) 472-4545 or

If any of the questions in this study made you uncomfortable in any way, or if participating in this study brought up any issues that are distressing for you, some resources that might be of assistance are provided below:
·       Betterhelp (online private counseling):
·       Psychology Today (find a therapist):
·       CRHSP (Canadian Register of Health Service Psychologists):
·       To find a Psychologist in Canada or the US:
·       Canadian Association for Suicide Prevention (links to local crisis centres):
·       National Suicide Prevention Hotline (US):
1-800-273-TALK (8255)                                              
·       Online peer support for LBGT individuals:
·       PFLAG Canada: Support, education and resources for parents, families, friends and allies to queer and trans communities
·       PFLAG USA:
·       Anti-Racism Resource Centre (CCRC - Canada):
·       Anti-Racist Alliance (USA):
·       If you have any concerns about a child at risk, please contact your local Child Protective Services or police
Attention: When completing this survey, please make sure that you are alone and undisturbed, and in a place where you feel comfortable to answer personal questions.
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