Consent Form
I__________________________ hereby give my consent for my participation in the research
study entitled, “Understanding Diabetes: Examination of the impact Socioeconomic Status has
on General Diabetes Knowledge and Compliance” This project will be conducted by Ari
Richelson under the supervision of David VanDyke, Ph.D. and Argosy University-Illinois
School of Professional Psychology/Chicago campus. There will be approximately 100
participants recruited for this study for the purposes of understanding how socioeconomic status
impacts knowledge and compliance of persons with diabetes. The present study is also to satisfy
the clinical research project (dissertation) portion of Argosy University’s doctoral program
requirements and is partly for educational purposes. I understand the only requirement of the
study is to complete three self-administered questionnaires which will last about 20-30 minutes.
I understand that the results of this study will be coded in such a way that my identity will
be completely protected and that all information disclosed will be kept strictly confidential. The
data collected will be destroyed subsequent to the completion of the project within five years. I
understand that this study will involve answering personal questions relative to my medical
history, demographics and personal values. I understand that I might experience adverse
feelings due to disclosure of personal information although this is a small possibility and that if
needed, a referral for help can be given at any time.
I understand that the present study is designed to examine the diabetes illness and the
effects it may have. The results of this study may be published or otherwise reported to other
scientific professionals but my identity will remain confidential. In addition, I understand that
the benefit of my participation in this study for the professional community will be to provide
data to the medical field in the area of diabetes research. Furthermore, I also understand that I
can personally benefit from this study by learning valuable information about my disease.
I understand that my participation is voluntary and that there is no penalty for early
withdrawal or requirement to continue throughout the entire study. Furthermore, I understand I
can refuse to answer any question on each survey. I also understand that each participant will be
provided with monetary compensation of $10 for participation. I understand that I have the right
to refuse participation at any time however, upon doing so, I will not receive compensation.
I understand that this research study has been reviewed and approved by the Institutional
Review Board, American School of Professional Psychology (formerly Illinois School of
Professional Psychology) at Argosy University, Chicago. For research related problems or
questions regarding participants’ rights, I understand that I may contact the Institutional Review
Board through Dr. David VanDyke, IRB chair, at 312-777-7600 ext. 7699 or by email at
DVanDyke@argosy.edu. Any additional questions or concerns can be addressed by Ari
Richelson, the primary researcher, at 708-990-3884 or by email at arichels@stu.argosy.edu.
Signature_______________________________ Date ________________________
Witness________________________________
Date ________________________
Participants wanted for Research Study
Examining Effects of Socioeconomic
Status on Type I Diabetes
$10 Monetary incentive will be offered for every participant interested in
helping.
Argosy University/American School of Professional Psychology
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
Doctoral student in clinical psychology program at Argosy University looking for
men and/or women aged 18 or older to participate in research study.
Study is looking for Persons with Type I Diabetes to examine the potential effects of
socioeconomic status on this disease.
Monetary compensation will be provided for participation. Compensation of $10 will be
given to each participant. Participants will be asked several questions during an initial
phone conversation to determine eligibility for this study. Subsequently, each participant
will be asked to complete the survey on their own. It will take approximately 20-30
minutes to complete three questionnaires. PARTICIPANTS ARE KINDLY ASKED TO
HONESTLY COMPLETE EACH SURVEY ENTIRELY ON THEIR OWN, WITHOUT
THE USE OF ANY RESOURCES OR HELP
Participants would not be eligible for this study if:
 They are under the age of 18
 Diagnosed with Type II Diabetes
 Diagnosed at age 16 or later with Type I Diabetes
 They have never been diagnosed with Type I Diabetes
To learn more about this research, please contact:
Ari Richelson - 708-990-3884
or
ARichels@stu.argosy.edu
This research is conducted under the direction of Dr. David VanDyke, Argosy University
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Have you been diagnosed with Type I Diabetes, Type II diabetes, or neither?
At what age were you diagnosed?
How old are you?
Approximately how much money did your mother earn when you were living with them?
Approximately how much money did your father earn when you were living with them?
If you live outside of Chicago, approximately how many miles outside the city do you
live?