Asian Body Pilot Survey

Asian Body Pilot Survey

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Consent Form


                              Asian American Body Image Scale Development: Pilot Study

                                               Principal Investigator: Frances Shen, PhD

                       Research Assistants: Brittany Sievers, Trenton Adams, and Ragini Srikrishna

                                             Institution: University of Illinois at Springfield

This research is being conducted by Dr. Frances Shen, an Associate Professor of Psychology at the University of Illinois at Springfield (UIS). The main purpose of this research is to develop a body image measure for Asian American men and women. This page will provide information about this research study. If you choose to participate in this research, you will be asked to read and indicate consent at the bottom of this page. You can print a copy of this page for your records.

You can participate in this research if: (1) identify as an Asian American man or woman, and (2) you are 18 years of age or older.

This research will consist of a survey that will last approximately 15 to 20 minutes. You will be provided with several items about Asian American body image-related experiences and attitudes. For each item, you will be asked to give feedback on its wording and clarity. The survey can be completed online on a computer at a location of your choice. No identifying information will be collected. The researchers will not know who supplied what answers. You will not be asked to provide your name, and all data from this study will be reported in a group format by gender. Data from this study will be stored on a password protected computer in a locked research office.

Your participation in this study is completely voluntary. Participants who complete the survey can enter into a lottery drawing to win one $25 gift certificate by submitting an email address at the end of the survey. To maintain anonymity of participant responses in the websurvey, you will be provided with a link at the end of the study that will bring you to a separate page for you to submit your email address. Winners will then be contacted via the email address provided. The odds of winning the certificate will depend on the number of participant entries, but can be estimated at 1 in 20. The drawing will take place at the end of the study, which is approximated for October 2014.

There are no foreseeable risks of psychological or physical harm to be encountered by participation in this research. However, if you experience any distress or discomfort from your participation, we suggest that you contact your university counseling center or community mental health agency. Note that you can end your participation at any time for any reason. There are no consequences if you decide not to participate. Even if you do participate, you do not have to answer every question or complete all parts of the survey.

There are no direct benefits for you participating in this study. However, your participation will contribute to greater knowledge and understanding of Asian American’s perceptions and experiences of body image.

This research is being conducted by Dr. Frances Shen, Associate Professor of Psychology at UIS, with Brittany Sievers, graduate research assistant at UIS, and Trenton Adams and Ragini Srikrishna, undergraduate research assistants at UIS. If you have any questions, concerns or complaints about this project, you can contact Dr. Frances Shen at or 217-206-7270.

This research has been approved by the UIS Human Subjects Review Officer, Dr. James Klein. Dr. Klein can be reached at 217-206-6883 to answer any questions about your rights as a volunteer participant in this research. This study will expire on 9/11/2015.

Consent Statement:

I have read this form. I understand that participation is completely voluntary. I understand there are no negative consequences if I don't participate. If I do participate, I know that I can discontinue my participation at any time and for any reason. By clicking the “continue” button below and completing the following items of the survey, I am indicating that I have read this form, I understand the nature of this research as described above, and I am giving consent for participation.

requiredBy choosing "continue", you are agreeing that you are at least 18 years of age or older.

requiredBy choosing "continue", you are agreeing that you are at least 18 years of age or older.