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This Informed Consent Form is for individuals that have experienced a trauma at least one year ago.

I volunteer to participate in a research project conducted by Natae Feenstra from The University of the Cumberlands. I understand that the project is designed to gather information comparing trauma symptoms between EMDR participants, runners, and no treatment. I will be one of approximately 276 people being assessed for this research. The completion of this survey is expected to take 20 minutes or less of your time.

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* 1. My participation in this project is voluntary. I understand that I will not be paid for my participation. As an incentive, upon completion of the survey, there will be an opportunity to enter an email address for a drawing for one of three $50 Amazon gift cards. I may withdraw and discontinue participation at any time without penalty. If I decline to participate or withdraw from the study, no one will be told.

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* 2. Participation involves:
  • Informed Consent Form
  • Demographic Questions
  • Trauma History Questionnaire
  • Trauma Symptoms Checklist 40

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* 3. I understand that my name will not be collected. The researcher will not be able to identify me by name in any reports using information obtained from the assessments, and that my confidentiality as a participant in this study will remain secure. Subsequent uses of records and data will be subject to standard data use policies which protect the anonymity of individuals and institutions.

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* 4. I understand that this research study has been reviewed and approved by the Institutional Review Board (IRB) at The University of the Cumberlands. For research problems or questions regarding subjects, the Institutional Review Board may be contacted at IRB@ucumberlands.edu.

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* 5. I have read and understand the explanation provided to me. I certify that I am at least 18 years of age. I voluntarily agree to participate in this study.

If you agree to all of the above, please enter your initials below.

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* 6. What is your gender?

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* 7. What is your age?

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* 8. What is your race or ethnicity?

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* 9. Do you have a trauma-related diagnosis from a health professional?

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* 10. Have you sought any psychological therapy or professional counseling for a Trauma Related concern IN THE PAST YEAR?

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* 11. Have you EVER sought any psychological therapy or professional counseling for any other mental health concern (not related to trauma)?

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* 12. IN THE PAST YEAR, have you sought any psychological therapy or professional counseling for any other mental health concern (not related to trauma)?

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* 13. Have you EVER participated in EMDR (Eye Movement Desensitization and Reprocessing)?

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* 14. Have you exercised regulary for the past year? (A regular exercise program being defined as intentional exercising three times a week for 30 minutes each time.)

Trauma History Questionnaire
The following is a series of questions about serious or traumatic life events. These types of events actually occur with some regularity, although we would like to believe they are rare, and they affect how people feel about, react to, and/or think about things subsequently. Knowing about the occurrence of such events, and reactions to them, will help us to develop programs for prevention, education, and other services. The questionnaire is divided into questions covering crime experiences, general disaster and trauma questions, and questions about physical and sexual experiences.

For each event, please indicate whether it happened and, if it did, the number of times and your approximate age when it happened (give your best guess if you are not sure). Also note the nature of your relationship to the person involved and the specific nature of the event, if appropriate.

Citation:
Hooper, L. M., Stockton, P., Krupnick, J., & Green, B. L. (2011). The development, use, and psychometric
properties of the Trauma History Questionnaire. Journal of Loss and Trauma, 16, 258-283.

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* 15. Has anyone ever tried to take something directly from you by using force or the threat of force, such as a stick-up or mugging?

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* 16. Has anyone ever attempted to rob you or actually robbed you (i.e., stolen your personal belongings)?

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* 17. Has anyone ever attempted to or succeeded in breaking into your home when you were not there?

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* 18. Has anyone ever attempted to or succeed in breaking into your home while you were there?

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* 19. Have you ever had a serious accident at work, in a car, or somewhere else? (If yes, please specify below)

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* 20. Have you ever experienced a natural disaster such as a tornado, hurricane, flood or major earthquake, etc., where you felt you or your loved ones were in danger of death or injury? (If yes, please specify below)

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* 21. Have you ever experienced a “man-made” disaster such as a train crash, building collapse, bank robbery, fire, etc., where you felt you or your loved ones were in danger of death or injury? (If yes, please specify below)

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* 22. Have you ever been exposed to dangerous chemicals or radioactivity that might threaten your health?

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* 23. Have you ever been in any other situation in which you were seriously injured? (If yes, please specify below)

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* 24. Have you ever been in any other situation in which you feared you might be killed or seriously injured? (If yes, please specify below)

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* 25. Have you ever seen someone seriously injured or killed? (If yes, please specify who below)

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* 26. Have you ever seen dead bodies (other than at a funeral) or had to handle dead bodies for any reason? (If yes, please specify below)

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* 27. Have you ever had a close friend or family member murdered, or killed by a drunk driver? (If yes, please specify relationship [e.g., mother, grandson, etc.] below)

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* 28. Have you ever had a spouse, romantic partner, or child die? (If yes, please specify relationship below)

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* 29. Have you ever received news of a serious injury, life-threatening illness, or unexpected death of someone close to you? (If yes, please indicate below)

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* 30. Have you ever had a serious or life-threatening illness? (If yes, please specify below)

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* 31. Have you ever had to engage in combat while in military service in an official or unofficial war zone? (If yes, please indicate where below)

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* 32. Has anyone ever made you have intercourse or oral or anal sex against your will? (If yes, please indicate nature of relationship with person [e.g., stranger, friend, relative, parent, sibling] below)

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* 33. Has anyone ever touched private parts of your body, or made you touch theirs, under force or threat? (If yes, please indicate nature of relationship with person [e.g., stranger, friend, relative, parent, sibling] below)

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* 34. Other than incidents mentioned in the previous two questions, have there been any other situations in which another person tried to force you to have an unwanted sexual contact?

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* 35. Has anyone, including family members or friends, ever attacked you with a gun, knife, or some other weapon?

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* 36. Has anyone, including family members or friends, ever attacked you without a weapon and seriously injured you?

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* 37. Has anyone in your family ever beaten, spanked, or pushed you hard enough to cause injury?

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* 38. Have you experienced any other extraordinarily stressful situation or event that is not covered above? (If yes, please specify below)

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* 39. How often have you experienced this symptom in the last month?
Headaches

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* 40. How often have you experienced this symptom in the last month?
Insomnia

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* 41. How often have you experienced this symptom in the last month?
Weight loss (without dieting)

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* 42. How often have you experienced this symptom in the last month?
Stomach problems

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* 43. How often have you experienced this symptom in the last month?
Sexual problems

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* 44. How often have you experienced this symptom in the last month?
Feeling isolated from others

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* 45. How often have you experienced this symptom in the last month?
“Flashbacks” (sudden, vivid, distracting memories)

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* 46. How often have you experienced this symptom in the last month?
Restless sleep

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* 47. How often have you experienced this symptom in the last month?
Low sex drive

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* 48. How often have you experienced this symptom in the last month?
Anxiety attacks

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* 49. How often have you experienced this symptom in the last month?
Sexual overactivity

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* 50. How often have you experienced this symptom in the last month?
Loneliness

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* 51. How often have you experienced this symptom in the last month?
Nightmares

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* 52. How often have you experienced this symptom in the last month?
“Spacing out” (going away in your mind)

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* 53. How often have you experienced this symptom in the last month?
Sadness

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* 54. How often have you experienced this symptom in the last month?
Dizziness

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* 55. How often have you experienced this symptom in the last month?
Not feeling satisfied with your sex life

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* 56. How often have you experienced this symptom in the last month?
Trouble controlling your temper

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* 57. How often have you experienced this symptom in the last month?
Waking up early in the morning

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* 58. How often have you experienced this symptom in the last month?
Uncontrollable crying

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* 59. How often have you experienced this symptom in the last month?
Fear of men

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* 60. How often have you experienced this symptom in the last month?
Not feeling rested in the morning

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* 61. How often have you experienced this symptom in the last month?
Having sex that you didn’t enjoy

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* 62. How often have you experienced this symptom in the last month?
Trouble getting along with others

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* 63. How often have you experienced this symptom in the last month?
Memory problems

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* 64. How often have you experienced this symptom in the last month?
Desire to physically hurt yourself

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* 65. How often have you experienced this symptom in the last month?
Fear of women

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* 66. How often have you experienced this symptom in the last month?
Waking up in the middle of the night

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* 67. How often have you experienced this symptom in the last month?
Bad thoughts or feelings during sex

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* 68. How often have you experienced this symptom in the last month?
Passing out

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* 69. How often have you experienced this symptom in the last month?
Feeling that things are “unreal”

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* 70. How often have you experienced this symptom in the last month?
Unnecessary or over-frequent washing

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* 71. How often have you experienced this symptom in the last month?
Feelings of inferiority

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* 72. How often have you experienced this symptom in the last month?
Feeling tense all the time

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* 73. How often have you experienced this symptom in the last month?
Being confused about your sexual feelings

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* 74. How often have you experienced this symptom in the last month?
Desire to physically hurt others

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* 75. How often have you experienced this symptom in the last month?
Feelings of guilt

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* 76. How often have you experienced this symptom in the last month?
Feeling that you are not always in your body

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* 77. How often have you experienced this symptom in the last month?
Having trouble breathing

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* 78. How often have you experienced this symptom in the last month?
Sexual feelings when you shouldn’t have them

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* 79. Thank you for completing this survey! Your time is appreciated. 

If, after taking this survey you feel the need to seek professional mental health treatment, here are some resources:

  • For free 24/7 support, text CONNECT to 741741 to chat with a crisis counselor
  • National Alliance on Mental Health (NAMI): The NAMI HelpLine can be reached Monday through Friday, 10 am–6 pm, ET.
    1-800-950-NAMI (6264) or info@nami.org
  • Substance Abuse and Mental Health Services Administration (SAMHSA): SAMHSA’s National Helpline, 1-800-662-HELP (4357), is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance abuse disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information.
  • For Veterans: National Center for PTSD 1-800-273-8255 or ptsd.va.gov
  • A simple online search can list mental health professionals in your area
  • In the case of an emergency, call 911

If you would like to know the results of this study, please email the researcher at nfeenstra3813@ucumberlands.edu.

If you would like to enter the drawing for one of three $50 Amazon gift cards, please enter your email address below.

Thank you and be well!

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