7/25/2019 Behavior Modification Program Consent Form (GS)

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Behavior Modification Program Consent Form

Terms discussed:

o You understand the purpose and goal of the Behavior Modification Programo You consent to the observation and modification of the target behavior

o You voluntarily agree to participate in the project.

o You understand that you are alloed to as! for clarifications and as! "uestions

involving the program.

o You agree to follo the program for its duration.

o You understand that the data is recorded and ill be shon to teacher#s$ or

students.o You understand that you have the right to confidentiality in the form of

pseudonyms or complete anonymity.

The Behavioral Modification Program is detailed belo:

o Goal:

%. To reduce the fre"uency of you tidying your hairo Program:

%. For the duration of the program& you ill agree to !eep trac! of the amount

of times the behavior is performed along ith other& relevant information

#'.g. '(ams& going to the mall etc.$). *ee! %:

%. +uring the program you are e(pected to a( your hair daily). , significant other ill message you at -: am& %): pm and /:

pm reminding you of the program./. 'ach day& if you do not perform the behavior more than %0 times by

1pm& you ill be given ice cream as a reard./. *ee! ):

%. ,s this is hen the effectiveness of the program is tested& the rules

of the first ee! are to be disregarded. You must still !eep trac! of

information hoever.o Duration:

%. To ee!s

By signing and dating this form along ith the researchers& you understand and agree

to the terms listed along ith the program itself.

Participant 2esearcher 2esearcher +ate and 3ignature +ate and 3ignature +ate and 3ignature