Participant Survey

Name

First NameLast Name

Email

example@example.com

Date of birth

Date

Gender

Are you color blind?

Have you ever received eye movement desensitization and reprocessing (EMDR) therapy?

If maybe, please explain.

Have you ever experienced a significant injury to the head? (e.g. concussion, hemorrhage, traumatic brain injury)

If yes, please provide details including if you experienced memory loss.

Have you ever been involved in a significant car accident? (multiple collision or car crash that involved serious bodily injury or fatalities)

Informed Consent:

*Your participation in this study is entirely voluntary, and you may decide to discontinue your participation at any time.

* Names will be kept confidential and only utilized for academic purposes. Data collected will be appropriately stored in an external encrypted drive to ensure confidentiality.

*The data will only be accessible by the primary researcher and co-researcher.

*No other personally identifiable information will be recorded as part of the research study. Results of the study will be shared in the final dissertation document and will not contain any identifiable information that would reveal or otherwise identify individuals who participated in the study.

Please select one of the options:

Date Signed

Date