DATA PRIVACY: The data that you enter on this form will be stored in REDCap, a secure web-based application for building and managing online surveys and databases. ALL other data related to our research is be stored on secure
servers maintained by our research laboratory. If you are uncomfortable entering your information using this form, please read the study information below, and if you are still eligible please contact a researcher by replying to the
email that was sent to you to set up a screening phone call.
Participant Form
Investigator: Dr. Tor D. Wager, CU Boulder
Thank you for your interest in this study. Before you come in to learn more about the study, it would be helpful to see if you are likely to qualify to be in the study. In order to do this, we would like to ask you some eligibility questions, which will include questions about pain, mental health history, medical history, and more. It should take about 5-10 minutes to go through these questions.
If you are eligible to participate in our pain studies, someone from our lab may then contact you to schedule a time when you can come into the lab. The first time you come into the lab, we will fill out additional questionnaires and do a basic pain test to make sure you are eligible to participate in additional studies. You will receive more information about that part of the study if you are invited to come in to the lab.
The purpose of these studies is to gain insight into the brain and behavioral mechanisms of pain processing. We want to understand pain perception by scanning your brain using functional magnetic resonance imaging (fMRI) and/or participating in laboratory experiments (no fMRI scanning). In addition to the fMRI measurements, we will collect physiological measurements like heart rate during the experiment.
During the fMRI and/or laboratory session you will be asked to perform a set of tasks. These may include 1) pressure stimulations applied to your fingernail that will be tolerably painful using a mechanical pressure device, 2) thermal stimulations applied to your forearm using a thermal pain delivery device that will also be tolerably painful.
The first part of this screening will take place on the web. If you are invited to participate in lab studies, they will take place at the Cognitive and Affective Neuroscience laboratory, located in the Muenzinger Psychology building on the University of Colorado - Boulder campus or at the Center for Innovation and Creativity (1777 Exposition Dr, Boulder, CO 80301).
You have the right to withdraw your consent or stop participating at any time. You have the right to refuse to answer any question(s) or refuse to participate in any procedure for any reason. Refusing to participate in this study will not result in any penalty or loss of benefits to which you are otherwise entitled.
You will not be paid for the basic online screening. Once you complete the basic screening, you may be offered the chance to participate in additional pain studies in our lab. You will be paid separately in cash for each study you participate in (generally between $12 and $25 per hour).
All the information you provide will be kept confidential and only accessible to members of the research team. If you are eligible, we will call or email you to provide further details about the study and see whether you'd like to participate.
We are also required to give you the number of University of Colorado Boulder IRB, the Ethics Board that oversees our research, in case you have questions or concerns for them: it is (303) 735-3702. The IRB is not able to answer specific questions about study participation. If you have questions about study participation, you may email ucbpainresearch@gmail.com with your questions or with your phone number and a team member will give you a call. If you complete the questions below, a study member will be in touch with you shortly regarding your eligibility and to provide more information about the study.
If you complete these screening questionnaires and are deemed eligible to participate in one or more of our studies, a member of our research team will contact you with more information about participation opportunities.
Would you like to be contacted?
* must provide value
Yes
No
AUTHORIZATION
By clicking "AGREE" below, I indicate that I have read the above about the study or it was read to me. I know the possible risks and benefits. I know that being in this study is voluntary. I choose to be in this study. I know that I can withdraw at any time.
* must provide value
What is the zip code of your current address?
Email Address
* must provide value
Preferred Contact Method:
List the best times to reach you by phone:
Use MTWRF for days followed by hours available (e.g., M 8-10am; WF 9-1pm, 3-5pm)
List blocks of two or more hours that you have available during the week between the hours of 8am and 8pm
Use MTWRF for days followed by hours available (e.g., M 8-10am; WF 9-1pm, 3-5pm)
Date of Birth:
* must provide value
Today M-D-Y
Female
Male
Other
What is your dominant hand?
* must provide value
Right
Left
Both
Ethnicity
* must provide value
What is your current or last occupation?
If you are or were a university student, what is/was your primary field(s) of study?
Are you interested in participating in pain studies?
* must provide value
Yes
No
Have you ever experienced any of the following?
If you do not wish to specify (this is preferred), use the "ONE OR MORE OF THE ABOVE" option
* must provide value
Do you have chronic pain? i.e. back pain, neck pain, knee pain, etc.
* must provide value
Yes
No
Do you have chronic low back pain?
Yes
No
Have you had any long term pain in the past?
* must provide value
Yes
No
Pain lasting more than 6 months
Is your long term pain fully resolved?
Yes
No
Do you have any other medical conditions which might make you especially sensitive to contact heat?
* must provide value
Yes
No
Do you have any other medical conditions which might make you especially sensitive to contact cold?
* must provide value
Yes
No
Do you have any reason to think that you are especially insensitive to contact pain in general?
* must provide value
Yes
No
Are you currently (within the last week) experiencing an unusual amount of pain?
* must provide value
Yes
No
Have you been a cigarette smoker or chewing tobacco user within the last 5 years?
Yes
No
If you smoke cigarettes, how often?
1/week or less 5/week or less 15/week or less 1 pack/day 2+ packs/day
How often do you consume alcohol
do not consume alcohol
one day per week
two days per week
three days per week
four or more days per week
How much exercise do you usually get?
Choose the option that fits you best
Almost none 1 hour/week 3 hours/week 7 hours/week 14+ hours/week
Do you train competitively in athletics?
Yes
No
Are you currently taking any prescription medication?
Yes
No
If you are currently taking medication, please list the name of each drug, your dose, how often you take it and when you started taking it.
Do you currently use any recreational drugs?
Yes
No
Please specify which recreational drugs you use. How often do you use them? When was the last time of use for each drug?
Have you had depressive episodes in the past?
Yes
No
Have you ever seen a psychologist/psychiatrist/other health care professional about these episodes?
Yes
No
If yes, please answer the following questions:
Did you receive a diagnosis?
Yes
No
Were you treated? Meds/CBT/other-what?
Have you ever been diagnosed with any of the following?
fMRI Studies
Entry into the MRI suite will bring you into the presence of a very strong magnetic field. Therefore, we request that you answer the questions so that we can determine whether it is safe and appropriate to allow you into the imaging suite.
Many of the studies in our lab involve brain scanning using MRIs. Participants in these studies are compensated at a rate of about $24/hour; however, the requirements for these studies are more restrictive. Are you interested in participating in MRI studies? If yes, answer questions in this fMRI study section.
* must provide value
Yes
No
Are any of the following true for you?
If you do not wish to specify (this is preferred), just check "ONE OR MORE OF THE ABOVE".
Do you have any of the following implants or items within your body as a result of any prior or recent medical experience?
If you do not wish to specify (this is preferred), just check "ONE OR MORE OF THE ABOVE".
Some IUDs are MRI safe, please feel free to contact our researchers for more information on IUDs to determine your MRI eligibility.
ucbpainresearch@gmail.com
Have you ever worked as a welder or machinist?
Yes
No
Have you ever had metal removed from your eyes?
Yes
No
Are you or could you possibly be pregnant?
Yes
No
If you need vision correction, do you only have glasses (not contacts)?
* must provide value
Yes, I only have glasses, not contacts.
No, I have both glasses and contacts.
I do not require corrective lenses.
Thank you for taking the time to fill out this information!
A member of our research team will review your information and contact you about any potential study opportunities for which you meet requirements.
Don't be surprised if you don't hear from us for a while; we're constantly starting new studies, and even if you're not eligible for any current study, we may contact you in future when an appropriate opportunity arises.
In the meantime, if you have any questions, or decide at any point that you'd like to withdraw from our pool of study volunteers, please email us at ucbpainresearch@gmail.com.
Thank you for your time, and we hope to be in touch with you soon!