Title of Research: Stories About Places That Matter

Ohio University Consent Form

Title of Research: Stories About Places That Matter

Researchers: Roger C. Aden

You are being asked to participate in research. For you to be able to decide whether you want to participate in this project, you should understand what the project is about, as well as the possible risks and benefits in order to make an informed decision. This process is known as informed consent. This form describes the purpose, procedures, possible benefits, and risks. It also explains how your personal information will be used and protected. Once you have read this form and your questions about the study are answered, you will be asked to sign it. This will allow your participation in this study. You should receive a copy of this document to take with you.

Explanation of Study

I am interested in learning how and why important places from our childhood linger in our memories. I also hope to learn how we draw upon those places, and our experiences within them, when we are adults.

If you agree to participate, you will be asked to write a brief account about a memorable place from your childhood. The story should describe the place in detail, explain what you did in the place, describe the most memorable event which occurred in the place, and reflect on why you still remember the place today.

Once you complete your story, your participation in this study will be complete—unless you would like to have your story included in a book collection of the stories received during this research (see below under Confidentiality and Records). You should email your story to the researcher at: .

Risks and Discomforts

No risks or discomforts are anticipated

Benefits

You may not benefit, personally by participating in this study—unless you wish to have your story included, with your name attached, in a book which contains some of the stories collected for this study.

Confidentiality and Records

Your story will be copied to a file on a password protected computer and then deleted from my email records. I will not identify you unless you wish to have your story includedin a book. Unless you express a desire to have your story considered for inclusion in a book, your identity will be kept confidential.

Additionally, while every effort will be made to keep your study-related information confidential, there may be circumstances where this information must be shared with:

* Federal agencies, for example the Office of Human Research Protections, whose responsibility is to protect human subjects in research

* Representatives of Ohio University (OU), including the Institutional Review Board, a committee that oversees the research at OU

Contact Information

If you have any questions regarding this study, please contact Roger Aden at or 740-593-4822.

If you have any questions regarding your rights as a research participant, please contact Chris Hayhow, Director of Research Compliance, Ohio University, (740)593-0664 or .

By signing below, you are agreeing that:

• you have read this consent form (or it has been read to you) and have been given the opportunity to ask questions and have them answered;
• you have been informed of potential risks and they have been explained to your satisfaction;
• you understand Ohio University has no funds set aside for any injuries you might receive as a result of participating in this study;
• you are 18 years of age or older;
• your participation in this research is completely voluntary;
• you may leave the study at any time; if you decide to stop participating in the study, there will be no penalty to you and you will not lose any benefits to which you are otherwise entitled.

Signature (or digital signature) Date

Printed Name

IN ADDITION:

IF YOU WOULD LIKE TO HAVE YOUR STORY CONSIDERED FOR INCLUSION IN A BOOK, PLEASE ALSO COMPLETE THE FORM BELOW. IF YOU COMPLETE THE FORM, YOU AGREE TO ALLOW THE RESEARCHER TO USE YOUR STORY IN A BOOK AND HAVE YOUR NAME ATTACHED TO THE STORY. IN SIGNING THIS FORM, YOU AGREE TO GIVE THE RESEARCHER RIGHTS TO YOUR STORY FOR PUBLICATION WITHOUT EXPECTATION OF COMPENSATION. YOU ARE NOT REQUIRED TO SIGN THIS PART OF THE FORM TO PARTICIPATE IN THE STUDY; SIGNING THIS PART OF THE FORM IS COMPLETELY VOLUNTARY.

Signature Date

Printed Name

Version Date: 11/11/14