California State Polytechnic University, Pomona

Informed Consent Form for Research Involving Human Subjects

Dear Online Psychology Students,

You are being invited to participate in a research study, which the Cal Poly Pomona Institutional
Review Board (IRB) has reviewed and approved for conduct by the investigators named here.
This form is designed to provide you - as a human participant - with information about this
study. The Investigator or his/her representative will describe this study to you and answer any
of your questions. You are entitled to an Experimental Research Participants Bill of Rights and
a copy of this form. If you have any questions about your rights as a participant, complaints
about the informed consent process of this research study, or experience an adverse event
(something goes wrong), please contact the Compliance Office within Cal Poly Pomonas Office
of Research at (909) 869-4215. More information is available at the IRB website,
www.csupomona.edu/research/irb.
Project Title: The E-Learning Classroom Environment
IRB Protocol Number: 14-0095
Principal Investigator: Felicia Friendly Thomas, PhD
Professor, PSY & SOC Department
Project Description
We are asking your permission to include the results of your work in this class (including Preand Post-test responses, Exam scores, Self-Assessment Surveys/Demonstrations, and course
grades) in this project designed to investigate student attitudes, characteristics and performance
in an e-learning environment.
Purpose
The purpose of this research project is to investigate the relationship among self-assessment
surveys/demonstration answers, attitudes, experiences with e-learning, and course grades. For
example, we are interested in exploring the relationship among surveyed personality
characteristics, course components, course grades, completion of course requirements, and elearning course satisfaction. We hope that this information might be useful in advising future
students as they grapple with the question, Which one is better for me - an on-line or a
traditional psychology course?
Voluntary and No Penalty
While you are expected to complete mandatory course requirements (e.g., exams, written
assignments, pre- and post-tests, self-assessment/demonstrations, etc), the inclusion of your
course data as a part of this research project is optional and will only be included in this
research project with your written permission. If you exercise your right to have your course
data excluded from this research project, you will not be penalized, i.e., you will receive class
credit for any and all completed work as outlined in the course syllabus and Guidebook.
Compensation
If you elect to have your course data included in this research project, you will receive 10 extra
credit points added to your Total Points for the course.

If you exercise your right to have your course data excluded from this research project but you
would like the opportunity to earn extra credit points, you may complete the following:
(a) Self-Assessment Essay - You may write a 600-word essay on your personal SelfAssessment score category for Self-Assessment #1, Self-Assessment #2, Self-Assessment #3,
or Self-Assessment #4. Note: A new link for this Essay has been created within the "Written
Assignment" link.
(b) Self-Assessment Questionnaires - You may complete Self-Assessments #5 and #6 for extra
credit points.
Confidentiality
If you agree to have your data included in this study, your results will be transferred outside of
Blackboard at the end of the quarter; your name will be removed from these results; and a
randomized number will be assigned to your information before data analyses begin. At this
point, your information will be anonymous.
Withdrawal
You may decide to withdraw your consent at any time prior to the removal of your name from
your class information and there is no penalty; and your extra credit points remain.
Harm
The only expectation for this research project is that you will allow the PI (instructor) to include
your class results in this E-Learning project. Therefore, it is not anticipated the study will not
present any legal, social, emotional, or psychological issues; present any physical or biological
hazards; reveal ones identity outside the Bb class environment; damage ones reputation in any
way; expose one to any medical illness, injury or side effects; or involve revealing or loss of
ones private information.
However, if participation in this study makes you feel uncomfortable in any way and you would
like to talk to a professional therapist, please feel free to contact the Cal Poly Counseling and
Psychological Services (CAPS) at (909) 869-3220. CAPS is located in the Bronco Bookstore
Building (Bldg. 66, Room 116); and CAPS services are free to Cal Poly students.
Results
Once the study is completed, we would be glad to give you a summary of the results. If you
have any questions at any time before or after the result are available, please feel free to
contact Dr. Felicia Friendly Thomas, Psychology and Sociology Department, California State
Polytechnic University, Pomona, 3801 Temple Ave., Pomona, CA, 91768, (909) 869-3799,
ffthomas@csupomona.edu.
Participants who wish summary feedback regarding the results of this project may send
a written request for feedback to the Principal Investigator (Dr. Felicia Friendly Thomas)
at ffthomas@csupomona.edu. Within your request, please indicate how you would prefer
this information be transmitted to you (via email or home address) and provide this
preferred contact information within this message. Please be aware that results may not
be immediately available when indicating your preferred method to receive feedback.

(Return this Consent Statement page only)

CONSENT STATEMENT: Please submit this entire Consent Statement page, including your
name clearly printed or typed on line 1, and your cursive handwritten (not printed or typed)
signature at the bottom where indicated. The other information/description above is not needed,
i.e., you may fax, scan, mail or deliver only this segment and keep the project description for
your records.
I, ___________________________________, hereby give my consent to participate in the
research study entitled The E-Learning Classroom Environment. I have read the above
information and am aware of the potential risks and complications.
I fully understand my participation is completely voluntary, and I may withdraw from this
research project at any time without prejudice or effect on my standing with this course or my
standing with California State Polytechnic University, Pomona. I also understand that I am free
to ask questions about techniques or procedures that will be undertaken.
Finally, I understand that all precautions will be undertaken to protect my identity; and that once
the information has been transferred outside of Blackboard my data will be assigned an
anonymous number that will not be connected to my name.
__________________________________
Participants signature

Date

I hereby certify that I have given an explanation to the above individual of the contemplated
study and its risks and potential complications.
_Felicia Friendly Thomas, Ph.D._________
Principal Investigator

___ May 22, 2015___

Date