California State Polytechnic University, Pomona
Informed Consent Form for Research Involving Human Subjects

You are being invited to participate in a research study, which the Cal Poly Pomona Institutional Review Board (IRB) has reviewed and approved for conduct by the investigators named here. This form is designed to provide you - as a human subject/participant - with information about this study. The investigator or his/her representative will describe this study to you and answer any of your questions. You are entitled to an Experimental Research Subject’s Bill of Rights and a copy of this form. If you have any questions about your rights as a subject or participant, complaints about the informed consent process of this research study, or experience an adverse event (something goes wrong), please contact the Research Compliance Office within Cal Poly Pomona’s Office of Research at the Research at 909.869.4215. More information is available at the IRB website,

Dear Student,

You have been selected to participate in the eCHECKUP TO GO survey. This nationally administered interactive online questionnaire for college students is maintained at San Diego State University and made available to Cal Poly Pomona so that we may provide you with information about alcohol, tobacco, and health. It is especially important that we are able to see what happens across time, so we need students like you to complete the questionnaire again now and each year in college. You will be rewarded incentives, like Cal Poly Pomona gift cards, for your continued participation.

The Wellness Center at Student Health and Counseling Services will also use this anonymous information to understand patterns of student alcohol use. The Cal Poly Pomona human subjects committee (IRB) has approved it for use here and assigned it the protocol number 15-0173. This online survey will help us provide better services and support for Cal Poly Pomona students. By completing the survey you may benefit from the individualized feedback that it will provide you. You can also benefit by knowing that you have assisted in providing accurate information regarding health/wellness behaviors on our campus. Although the video at the beginning of the survey indicates that its original purpose was to provide you with information and not provide us with information, we would like to use the data gathered from the survey to develop health and wellness programs for the CPP campus community. If you are interested in learning about the results of the study, please feel free to contact the researchers at or

The eCHECKUP TO GO is completed online. We encourage you to complete the survey in one sitting, which typically takes about 15-20 minutes, including viewing the information provided. The online program will generate a unique ID number for you, that will only be known to you. The unique ID number is not connected to your data. Please make note of this number, as you will need it to return to the program in the future. If you do not write down or photograph the ID number at the beginning of the survey, or take a screen shot of it, you may also find it in the output summary that you may view or print at the end of the survey.

There may be some personal discomfort with the content of certain questions. For example, there are questions regarding alcohol use. If you’d like to talk with someone about personal issues addressed in the survey, you may contact the Wellness Center at (909)869-5272 or Counseling Services at (909)869-3220.

Your participation is completely voluntary and anonymous. There are not questions that would identify you, only that someone of your age and gender completed the survey at that time. Any reports or publications will be based on the data of the group and cannot identify any individual as being affiliated with this project.

By taking this survey, you acknowledge that you consent to participate in the study. You agree that the purpose of this study has been satisfactorily explained to you.  You understand you are free to discontinue participation at any time if you so choose and that the researchers will gladly answer any questions that may arise during the course of the research.  Refusing or withdrawing from this study will be at no penalty or loss of benefits to you.

If you have any questions, please contact Jonathan Martinez (moderator of the eCHECKUP TO GO at Cal Poly Pomona) at Student Health and Counseling Services. Jonathan Martinez

If you agree to participate in the eCHECKUP TO GO  survey, click on the following Internet address to continue:

Thank you for your participation! Remember to save your unique ID number!

Carla Jackson, MPH
Health Educator
SHCS Wellness Center

and James Sturges, PhD
Professor, Psychology and Sociology Dept.