Informed Consent Form

1. PURPOSE OF THIS RESEARCH STUDY
You are being asked to participate in a research study designed to examine the relationship between
memory loss after a concussion and symptoms of depression. We will analyze responses to surveys
regarding concussion symptoms and mental health. The study is intended to show whether there is a
correlation between memory loss as a concussion symptom and developing depression later in life. The
purpose is to provide more data surrounding the issue of brain injuries and mental health to help athletics
personnel provide better care to athletes who sustain a head injury.

2. PROCEDURES
You will be asked to complete surveys on demographics and activity level to determine whether you fit
the criteria for the study. Then, you will fill out a survey asking about your history of head injuries and
mental health.
In total, your participation in this study should take no more than 45 minutes.

3. POSSIBLE RISKS OR DISCOMFORT
Risks of this study are minor and will not include physical risk. Minor risks include possible
inconvenience of the time it takes to complete questionnaires, and possible discomfort when recounting
head injury history and mental health history.
Any new information developed during the study that may affect your willingness to continue
participation will be communicated to you.

4. POSSIBLE BENEFITS
Benefits from this study include allowing us to see if there is a correlation between certain concussion
symptoms, specifically memory loss, and depression later in life. This is useful towards the advancement
of scientific knowledge because it could show a link between the areas of the brain responsible for
depression and the areas responsible for memories, or memory loss. If there seems to be a correlation
between memory loss and depression, this will allow coaches, athletic trainers, and other sports personnel
to better monitor an athlete for depression symptoms.

5. FINANCIAL CONSIDERATIONS
There is no financial compensation for your participation in this research, participation is voluntary and
participants may stop at any time.

6. CONFIDENTIALITY
Your identity in this study will be treated as confidential. The results of the study, including laboratory or
any other data, may be published for scientific purposes but will not give your name or include any
identifiable references to you.
However, any records or data obtained as a result of your participation in this study may be inspected by
the sponsor, by any relevant governmental agency, by the George Fox Institutional Review Board, or by
the persons conducting this study, provided that such inspectors are legally obligated to protect any
identifiable information from public disclosure, except where disclosure is otherwise required by law or a
court of competent jurisdiction. These records will be kept private insofar as permitted by law.
We will keep records of the data on an excel sheet and have you fill out a form of information using an
identification number rather than your name. We will have a separate list of first names to numbers for
our identification which will be deleted after study completion. We will also use general confidentiality
practices, as no data will be shared with individuals outside the research team unless it is deemed necessary to protect your personal health and well-being. All data will be stored
on a locked, password-protected computer. Identification numbers will not be used on presentation
posters, so there will be virtually no way to identify your data.

7. TERMINATION OF RESEARCH STUDY
You are free to choose whether or not to participate in this study. There will be no penalty or loss of
benefits to which you are otherwise entitled if you choose not to participate. You will be provided with
any significant new findings developed during the course of this study that may relate to or influence your
willingness to continue participation. In the event you decide to discontinue your participation in the
study, please notify one of the principal investigators (Madeleine O’Hare, mohare18@georgefox.edu or
Franklin Leonard fleonard18@georgefox.edu), so that your participation can be orderly terminated.

8. AVAILABLE SOURCES OF INFORMATION
Any further questions you have about this study will be answered by the Principal Investigators:
Name: Madeleine O’Hare
Email: mohare18@georgefox.edu
Name: Franklin Leonard
Email: fleonard18@georgefox.edu
Any questions you may have about your rights as a research subject will be answered by:
Name: Mary Imboden
Email: mimboden@georgefox.edu
In case of a research-related emergency, call:
Day and Night Emergency Number: 541-250-9207

9. AUTHORIZATION
I have read and understand this consent form, and I volunteer to participate in this research study. I
understand that I will receive a copy of this form. I voluntarily choose to participate, but I understand that
my consent does not take away any legal rights in the case of negligence or other legal fault of anyone
who is involved in this study. I further understand that nothing in this consent form is intended to replace
any applicable Federal, state, or local laws.