My name is Allyson Bradow and I am a graduate student at Spalding University in Louisville, Kentucky. I am conducting a research project as part of my graduate program in Clinical Psychology. The general goal of my research project is to investigate the psychological symptoms associated with infertility diagnosis and treatment. There are no direct benefits to your participation. I am asking if you would volunteer to participate in my research.
Your participation will require you to answer questions related to your experience with infertility.
I expect that it will require about 10-15 minutes of your time.
The results from your participation will be anonymous. Your name will not, and can not be associated with your data. No identifying information is asked for, and therefore can not be linked to your data. In addition, all data will be presented in grouped form, and the results from any one individual will never be presented.
I judge the risks to your participation to be minimal. An emotional response may be elicited from the questionnaire and the request that you think about a time that may have been emotional for you. If you should experience something that causes significant distress as a result of your participation, please discontinue the survey and seek mental health assistance via the American Psychological Association website (http://locator.apa.org) or the Association of Behavioral and Cognitive Therapies website (www.abct.org). You may also call the National Mental Health Association at 1-800-969-6642. In addition, please contact me at any time if you have any questions regarding this research or to obtain results. My name and e-mail address are given below.
I will assume your return of the completed questionnaire is an indication of your willingness to participate in this research, that your are sufficiently informed of what is expected of you, that you are aware of the level of risk and you know how to contact me if should you have questions. Please keep this form for future reference if needed.
Investigator Contact Information:
Name: Allyson Bradow, MA, LPA
E-mail: allysonbradow@spalding.edu
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| My relationship status is |
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| The highest level of education I have completed is |
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I approximate my household income to be
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| I have ___ child/children |
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| I was able to conceive and carry a child to term prior to my infertility diagnosis. |
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| I have changed partners since I was able to conceive and carry a child to term |
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| How long did you try to conceive without intervention prior to seeking treatment? |
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| How long did it take for the medical specialist to make a diagnosis? |
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| How long have you been receiving treatments/intervention for infertility? (if you are no longer pursuing intervention, please indicate how long you did receive treatment prior to stopping) |
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| What would you estimate you have spent on infertility diagnosis and treatment? |
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| My healthcare provider whom I had the most contact and interaction with during diagnosis and/or treatment of infertility was |
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| I would consider my healthcare provider's temperment to be |
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| I felt that my healthcare provider understood my emotional experiences and was sensitive to my situation |
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| Instruction to participant: Think about your experiences with infertility diagnosis and treatment. Please read each question carefully and select which category accurately indicates if and how much you have had each experience in relation to infertility diagnosis and treatment. |
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| Repeated, disturbing memories, thoughts, or images related to infertility diagnosis and/or treatment? |
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| Repeated, disturbing dreams related to infertility diagnosis and/or treatment? |
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| Suddenly acting or feeling as if experience were happening again (as if you were reliving it)? |
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| Feeling very upset when something reminded you of infertility diagnosis and/or treatment? |
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| Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of infertility diagnosis and/or treatment? |
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| Avoiding thinking about or talking about, or avoid having feelings related to infertility diagnosis and/or treatment? |
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| Avoiding activities or situations because they remind you of infertility diagnosis and/or treatment? |
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| Having trouble remembering important parts of infertility diagnosis and/or treatment? |
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| Losing of interest in things that you used to enjoy? |
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| Feeling distant or cut off from other people? |
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| Feeling emotionally numb or being unable to have loving feelings for those close to you? |
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| Feeling as if your future will somehow be cut short? |
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| Having trouble falling or staying asleep? |
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| Feeling irritable or having angry outbursts? |
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| Having difficulty concentrating? |
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| Being “super alert” or watchful on guard? |
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| Feeling jumpy or easily startled? |
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| Experiencing marital conflicts since diagnosis/treatment of infertility? |
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| Having difficulty with other interpersonal relationships since diagnosis/treatment of infertility? |
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| Feeling less able to control your emotions or react like you used to since diagnosis/treatment of infertility? |
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| Finding yourself doing things impulsively or without thinking since diagnosis/treatment of infertility? |
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| Feeling shameful since diagnosis/treatment of infertility? |
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| Feeling hopeless since diagnosis/treatment of infertility? |
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| Withdrawing from other people and things that you used to enjoy since diagnosis/treatment of infertility? |
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| Feeling hostile since diagnosis/treatment of infertility? |
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| Feeling that your personality has changed since diagnosis/treatment of infertility? |
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| Hearing or seeing things that were not there since diagnosis/treatment of infertility? |
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| Feeling your beliefs about yourself and the world are different since diagnosis/treatment of infertility? |
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| Prior to your experience with infertility, were you ever given a mental health diagnosis? |
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| If yes, what diagnosis have you been given? | |
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| How did you hear about this survey? | |
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| Is there anything that you would like me to know about your experience with infertility or with this survey? | |
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