Irb

NORTHEASTERN STATE UNIVERSITY
Institutional Review Board

IRB #

INSTITUTIONAL REVIEW BOARD
APPLICATION

If you would like to consult an IRB committee member about your application before
submitting it, the following members are available during their office hours:
Dr. Ernst Bekkering and Dr. Vanessa Anton
Prior to completing this application, please review the NSU IRB Policies & Procedures at
http://arapaho.nsuok.edu/~irb .

For IRB use only: ___ Exempt ___ Expedited ___ Full Board Review

Project Title:
Adult Attention Deficit Disorder: Impact on Quality of Life
*Note: The project title should be consistent with the title used in the consent document(s).

PART I - INVESTIGATOR and KEY RESEARCH PERSONNEL
1) PRINCIPAL INVESTIGATOR (PI)/CONTACT
Name:

__ Dr. __Mr. x Ms. _ _ Mrs.

Lisa Josey

Investigator Status:
E-mail Address:
College/Department:
Preferred Mailing Address:

__ Faculty
__ Graduate Student
__Optometry Student

josey@nsuok.edu
College of Education/Department of Psychology &
Counseling
PO Box 140095
City: Broken Arrow

Daytime Phone:

_x_ Undergraduate
__ Other: ____________

State: OK

Zip:74014

918.607.3656

2) FACULTY SPONSOR OR CO-INVESTIGATOR (if applicable)
Name:

E-mail Address:
College/Department:
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April Phillips
_X_Faculty
Sponsor

_X_ Dr. __Mr. __ Ms. __ Mrs.
Co-investigator:
__Faculty __ Graduate Student __ Undergraduate
__Optometry Student
__ Other: ________

philli48@nsuok.edu
College of Education/Department of Psychology &
Counseling
3100 East New Orleans

Revision Date: 9/6/2011

City: Broken Arrow
Daytime Phone:

State:OK

Zip:74014

(918) 449-6356

If more space is needed to list additional co- investigators please copy and paste this section.

ADDITIONAL CO-INVESTIGATOR (if applicable)
__Dr. __Mr. __Ms.

Name:

__Faculty
Sponsor

Co-investigator:
__Faculty __ Graduate Student __ Undergraduate
__Optometry Student
__ Other: ________

E-mail Address:
College/Department:
City:

State:

Zip:

Daytime Phone:
Please be aware that the IRB will only consider applications that all investigators, and, if
applicable, the Faculty Sponsor have signed on the signature page at the end of the
document.
PART II – FUNDING INFORMATION
1) Check all of the appropriate boxes of funding sources for this research. Include pending
funding source(s).
__University
__

__College: ________

Other: ________

__State

__

Federal

__N/A

P.I. of Grant or Contract:
Sponsor:
Contract/Grant No.
(if available):
Contract/Grant Title:
Please attach one complete copy of the proposal submitted to the sponsor. Submission of your grant
application is a regulatory requirement and will be maintained for the record with your application.
You must submit all necessary documentation for this application, such as consent forms and survey
questionnaires, in addition to the copy of the grant, even if those forms are included in the grant
application.

PART III – ADMINISTRATIVE DATA
RESEARCH MUST NOT BE INITIATED UNTIL YOU RECEIVE AN APPROVAL LETTER FROM THE IRB
If you are notified that your application has been evaluated as acceptable contingent on certain changes,
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you must not start data collection until you have submitted the requested changes and received notification
that the revised application has been fully approved. Starting data collection before receiving documentation
of study approval constitutes research misconduct as defined in the university policies.

1) Proposed start date: ____

____

or ____X____ upon IRB approval

2) Please check the most appropriate box.
_X_ Course Project (student)
__ Honors Project (student)

__
__

Thesis (student)
Research Project (faculty)

Capstone (student)
__Optometry Project
__

Approvals will be granted for up to one year. After this time, apply for an extension by email to irb@nsuok.edu.
Records will be retained until five years after last approval end date.

3) Will medical clearance or screening be necessary for subject recruitment because of inclusion
or exclusion criteria, administration of substances such as food or drugs, or physical exercise
conditioning?
No_X_
Yes __
If yes, explain how clearance will be obtained. If a screening instrument will be used, please attach a
copy to the application, or copy the text of the instrument in the box below.

4) Study Sites:
__NSU-Tahlequah

__NSU-Muskogee

_X_NSU-Broken

__

Arrow

Other: __ONLINE______

5) Potentially Vulnerable Populations :
Please check any groups included in the study. Inclusion of any group below requires full
board review):
__Children

(under 18 years of
age)
__Pregnant Women
__Elderly (65 & older)
__Psychologically Impaired

__Cognitively

Impaired

__Prisoners
__Native

American Tribes and/or Tribal Organizations
__Students enrolled in a class in which the instructor is
an investigator in the study

6) Other Institutional or External Oversight (if applicable):
Check the items listed below that apply to this research project:
__NSUOCO

(Optometry) Student Projects Committee
__Cherokee Nation IRB
__IHS Oklahoma Area Office IRB
__Other institutional oversight committee________
Note: This information may be forwarded to the appropriate University personnel and/or committee(s).

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7) Conflict of Interest
Is there any potential or perceived conflict of interest between the researcher, sponsor and/or
Northeastern State University associated with this study?
No_X_
Yes __
If yes, please explain: ________
Please refer to NSU IRB Policies on Conflict of Interest. Additional information may be requested by the IRB Board.

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PART IV – SUMMARY OF STUDY ACTIVITIES
Submission of a copy of a grant application does not replace completion of this form. Please
respond to each item. Incomplete forms will be returned.
1) Provide background information for the study in the box below, including the objective of the
proposed research, purpose, research question, hypothesis and any other relevant
information.

A democratic political system operates on the grounds of compromise. Without this critical
element, Congress’ ability to pass important legislation is severely damaged. This concept was quite
evident during the recent debt-ceiling debates, a situation that amplified the severity of the political
divide between democrats and republicans. As America and the rest of the world watched in
trepidation, Congress fell into a downward spiral of poor leadership and nonexistent cooperation. As
the deadline to reach a deal drew closer, the stock markets took violent swings due to the uncertainty
investors felt about Congress’ ability to work together and reach a comprehensive, balanced plan to
address the budget deficit.
On August 5th, 2011, Standard and Poor’s lowered its long-term sovereign credit rating on the
United States of America to AA+ from AAA. According to S&P’s website, “…the downgrade reflects
our view that the effectiveness, stability, and predictability of American policymaking and political
institutions have weakened at a time of ongoing fiscal and economic challenges to a degree more than
we envisioned when we assigned a negative outlook to the rating on April 18, 2011.”
( www.standardandpoors.com).
This fiasco, as well as other examples of the same inflexible behavior on the part of those
individuals whose job it is to work together in the best interest of this nation, has made clear the
deepening divide along party lines and the inability of those on either side to come together and work
efficiently. The question then, is whether this epidemic of partisan extremism is confined to America’s
politicians, or if this trend is evident in the political views of everyday American citizens as well.
The current study is predicting that there will be differences in the willingness to compromise
between democrats and republicans. In addition, the researchers will analyze correlations between each
demographic factor as it relates to the individuals’ willingness to compromise.
2) Describe the research design of the study in the box below.
Single administration survey examined as a Correlational study.
3) Describe the tasks that participants will be asked to perform in the box below. Include a
step-by-step description of the procedures you plan to use with your subjects. Provide the
approximate duration of subject participation for each procedure. If data collection
instruments will be used, indicate the time necessary to complete them, and the frequency
and method of administration, such as telephone, mail, or face-to-face interview.

This study will be conducted as an anonymous survey administered either by the researcher via a paper
and pencil survey or online using the CheckBox survey program available through Northeastern State
University. Participants will first read and agree to the terms described in the informed consent
document. Participants will be given scenarios describing a political issue in which republicans and
democrats tend to disagree. Participants will be asked to indicate whether or not they would support the
described legislation as well as how willing they would be to compromise. In addition, basic
demographic information will be collected including political affiliation, age, gender, and education
level. Once participants have completed the packet, they will be thanked for their time and allowed to
ask any questions about the study. We anticipate that the entire survey will take most participants less
than 20 minutes to complete.
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Attach a copy of each study instrument, or copy the text of the instrument in the box below.
This includes all questionnaires, surveys, protocols for interviews, etc.

All materials are attached in appendix A, B, and C.
4) Describe the recruitment procedures. Attach a copy of any material used to recruit subjects,
or copy the text of those materials in the box below. Materials can include advertisements,
hand-outs, telephone scripts, verbal recruitment scripts, cover letters, etc. Explain who will
approach potential participants and what will be done to protect the individual’s privacy in
this process.

Participants will be invited to participate in the study online through the social networking website
Facebook, and via various email list-serves. Students at NSU may also be recruited to participate in
person or online through the use of flyers placed in various locations on campus. With the permission
of individual instructors, the researcher will recruit students in person by making short announcements
in class. Participants who choose to participate in the study can either complete the online version at
their convenience or may contact the researcher to make an appointment to complete the study in
person. Thus, the identity of anyone who chooses to participate will be kept confidential.
A copy of the flyer that will posted on campus and/or passed out in classes is included in
Appendix B.

PART V – PRIVACY PROCEDURES

1. Will you record any direct identifiers, names, social security numbers, addresses, telephone
numbers, etc?

No_X_

Yes __

If yes, explain why it is necessary to record findings using these identifiers. Describe the coding
system you will use to protect against disclosure of these identifiers. Describe how subject identifiers
will be maintained or destroyed after the study is completed.
________

2. Will you retain a link between the study code numbers and direct identifiers after the data
collection is complete?

No_X_

Yes __

If yes, explain why this is necessary and state how long you will keep this link.
________

3. Will you provide a link or identifier to anyone outside the research team? No _X_

Yes __

If yes, explain why and to whom. ________

4. Will audio, video, film, or digitally captured data be recorded? No_X_

Yes __

Please explain how the disposition of the recorded data (tapes/photographs/negatives or
digital/electronic media) will be handled. Indicate if recorded data will be erased or destroyed at
the conclusion of the study. If you wish to retain the recorded data beyond the conclusion of the
study, you must provide justification. Subjects must be informed of the disposition of any recorded
data via the informed consent process . ________

Please clarify how subjects will be identified in audio/video/film/digitally-captured
responses. __________
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5. Where, how long, and in what format (such as paper, digital or electronic media, video,
audio or photographic) will data be kept? Describe what security provisions will be taken
to protect this data (password protection, encryption, etc). Finally, specify when and how
the data will be destroyed.

Date will be entered into an Excel file for storage and transferred to SPSS for analysis. Only those
individuals directly involved in the study will have access to these data files. No identifying
information will be collected from the participants. Therefore, there will be no way to identify
individual participants’ responses once the data has been collected. Surveys that are completed in a
paper and pencil format will be stored in a locked office and only the faculty sponsor (Dr. Phillips)
will have access to them. Once the study is complete, these paper surveys will be shredded and
disposed of.
6. Will you place a copy of the consent form or other research study information in the
participant’s medical, personal or educational record? (This information should be clearly
explained in the consent document and/or process)
No _X_
Yes__
If yes, explain why this is necessary. ________

7. Will you require a Federal Certificate of Confidentiality?

No _X_

Yes __

If yes, submit documentation of application (and a copy of the Certificate of Confidentiality
award if granted) with this application form.
If the data collected contains information about illegal behavior, visit the NIH Certificates of
Confidentiality Kiosk http://grants1.nih.gov/grants/policy/coc for information about obtaining a
Federal Certificate of Confidentiality.

8. Will any record of the subject’s participation in this study be made available to his or her
supervisor, teacher, or employer? No_X_

Yes __

If yes, please explain. ________

PART VI – INFORMED CONSENT INFORMATION
1) Informed Consent: Please attach a copy of all informed consent forms, or copy the text of
these documents in the box below.
a. If subject participation is anonymous, IRB recommends including the text of an
information sheet or cover letter containing all required elements of informed consent.
b. If subject participation is not anonymous, you MUST include the text to the consent
form.
i. For children and youth participants , provide both the text for the assent form for
the child/youth and the text of a permission form for the parents
ii. For adult participants, include the text for the consent form.
View sample Informed Consent Documents at http://arapaho.nsuok.edu/~irb/
See attached materials in Appendix A

PART VII – RISKS AND BENEFITS
1) Does the research involve any of the following possible risks or harms to subjects?
No _X_
Yes __ (if YES, a FULL BOARD REVIEW is required)
Check all that apply:
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__Use

of deception*

*If deception is used, describe this in detail in the box below. This includes the debriefing process
and the debriefing script. The principal investigator must offer the participant the opportunity to
withdraw his/her data after finding out that deception was used in the study.
__Use

of confidential records (e.g. education or medical records)
__Manipulation of psychological or social variables such as sensory deprivation, social isolation,
psychological stressors
__Any probing for personal or sensitive information in surveys or interviews
__Presentation of materials which subjects might consider sensitive, offensive, threatening or
degrading
__Possible invasion of privacy of subject or family
__Risk of physical injury or harm
__Social or economic risk
__Legal risk
__Employment/occupational risk
__Other risks, specify: ________

2) Describe the nature and degree of the risk or harm checked above. The described
risks/harms must be disclosed in the consent form. ________

3) Explain what steps will be taken to minimize risks or harms and to protect subjects’ welfare. If
the research will include protected populations (See Part III, Item 6), identify each group and
answer this question for each group. ________

4) Describe the anticipated benefits of this research for individual participants in each subject
group. If none, state “none”. ____none____

5) Describe the anticipated benefits of this research for society, and explain how the benefits
outweigh the risks. This study seeks to discover the degree of political extremism possessed by
average American citizens. Implications of this study may be used to better understand recent
political trends and how they relate to the political beliefs of citizens of this country.
PART VIII – COMPENSATION INFORMATION
Will any compensation or inducements, i.e. course credit, be offered to the subjects for their
participation?
No_X_
Yes __
If yes, describe those inducements and include a statement in the informed consent document
explaining how compensation will be handled in the event the participant withdraws from the study.
________

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EMAIL Submissions

Paper Submissions

Form : save this file( in Microsoft
Word format ) and send it AS AN EMAIL
ATTACHMENT to: irb@nsuok.edu
In the body of the application, include as
appropriate, Solicitation Announcements/
Recruitment materials, Data Collection
Instruments/(ie., Interview questions/
Questionnaires/Surveys), Informed Consent
Documents (Parental/Legal Guardian Permission
Form, Child Assent Form), Medical Screening
Instrument, Proposal and/or Contract or Grant,
Debriefing Script (for studies involving
deception) or copy and paste them to the back
of the document.

We strongly discourage the use of paper submissions. For
legacy purposes, we will continue to accept them.
However, please be aware that processing and approval
will be significantly slower than emailed applications for the
following reasons:
•
Applications must be routed to the Graduate
Office, and then forwarded to the IRB Chair
•
Applications must be office mailed to the
reviewers. This usually takes two days
•
At least one reviewer must return the application so
the Chair can interpret the reviewer comments.
Office mailing usually takes two days
•
If the application is lost en route, there is no trail or
tracking possible.

_X_Application

Upon receipt of the emailed application, all
investigators will receive a confirmation email
with the signature page. Print out the email and
send it (signed) to
Dr. Ernst Bekkering
IRB Chair
College of Business and Technology
Room 221 i
Northeastern State University
Tahlequah, OK 74464
Faxed copies and digitally signed files are not
acceptable.
Only submit ONE file. Emails with more than one
file will not be accepted. If you have separate
PDF files, Word files, etc, copy and paste them to
this Word document. Alternatively, print them
out, send them by mail, and indicate below
which documents will be mailed.
Below, check off which documents will be
mailed to the IRB Chair
__Approval from Study Sites (ie, public schools)
__Other: (if applicable)_________________________

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__Application

Form : THREE COPIES
Mrs. Kathy Schoonover
Director, Research and Sponsored Programs
Administration building room B19
Tahlequah, OK 74464
__Solicitation Announcements/Recruitment materials
__Data Collection Instruments/(ie., Interview
questions/Questionnaires/Surveys)
__ Informed Consent Documents
__Parental/Legal Guardian Permission Form
__Child Assent Form
__Approval from Study Sites (ie, public schools)
__Medical Screening Instrument
__Proposal and/or Contract or Grant
__Debriefing Script (for studies involving deception)
__Appendices

(if applicable)

Appendix A
Informed Consent Form

CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Title of Project: Bipartisan Negotiations
Principal Investigator(s): This study is being conducted by XXXXXXX under the direction of Dr. April
Phillips (philli48@nsuok.edu)
Purpose of the Study: The current study aims to explore factors that may influence ones’ willingness to reach
bipartisan compromise.
Procedures to be Followed: After participants read and understand this informed consent form, they can begin
filling out the survey. The Bipartisan Negotiation Survey addresses four pieces of controversial legislation from
the state or federal governments. Each issue is followed by three arguments from both those who oppose and
those who support the proposed legislation. After participants read the arguments, they are asked a series of
questions about their opinion on the issue. Participants will then be asked to provide some demographic
information.
Discomforts and Risks: There are no risks associated with your participation in this study and we do not
anticipate any discomfort.
Benefits: Although there are no direct benefits to you for participating in our study, your participation will
allow us to expand our knowledge about how people approach controversial negotiations. Implications of this
study may also be used to better understand recent political trends and how they relate to the political beliefs of
citizens of this country.
Costs or Compensation: Your participation in this study is strictly voluntary. There is no cost or compensation
associated with your participation in this study.
Duration: Approximately 20 minutes
Statement of Confidentiality: Your participation in this study will be kept completely confidential. We will
not be collecting your name or any other identifying information in this study, thus, your responses will be
anonymous and there will be no way for anyone to identify your responses. The original data sheets and the
electronic file with your data will be stored in a locked office and only those individuals who are directly
involved in the study will have access to your information. Finally, findings from this study will be presented in
aggregate form with no identifying information to ensure confidentiality.
Right to Ask Questions: You have the right to ask any questions during and after you participate in this study.
Participants may contact Dr. April Phillips at (918) 449-6356 or email philli48@nsuok.edu with any questions
about the study. You may also contact the Institutional Review Board at Northeastern State University at (918)
444-2917 or irb@nsuok.edu.
Voluntary Participation and Right to Withdraw: You must be at least 18 years old to participate in this
study. Participation in this study is completely voluntary. You have the right to refuse to participate. You also
have the right to withdraw from the study at any time without penalty. You also have the right to refuse to
Page 10 of 17


answer any individual questions without withdrawing from the entire study; however, we strongly encourage
you to answer all questions, since failing to do so could invalidate your results
My signature below indicates that I have read the information above and that I agree to participate in this study.
I can ask for a copy of this consent form.
_______________________________________
Signature of Participant

_____________
Date

_______________________________________
Printed Name of Participant
_______________________________________
Investigator’s Signature

_____________
Date

Instead of the signature lines above, we will use the following text for participants who complete the study
online through CheckBox:
Clicking the "Next" button below and proceeding to the questions indicates that I have read the information
above and that I agree to participate in this study. I can print out this web page for your records.

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Appendix B
Example Recruitment Flyer

Research Participants Needed!
(Must Be 18 or older)

Bipartisan Negotiation Study
This study aims to examine processes involved in
political negotiations. You do not need to be a
political expert to participate, this study is seeking
opinions about well known political issues that affect
people’s everyday lives. Participation in this survey will
require approximately 20 minutes and can be
completed online or in person by appointment.
Call or email for more information!
XXXXXXX
(XXX)XXX-XXXX
XXXXXXXXXX
or
Dr. April Phillips
(918)449-6356
Philli48@nsuok.edu

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Appendix C
Bipartisan Negotiation Study

Bipartisan Negotiation Survey
Instructions: You will be presented with four political issues. Following each issue will be three arguments from
those who oppose the legislation and three arguments from those who support it. After reading all arguments
from both sides of the issue, respond to the questions that follow regarding your position on the issue and your
willingness to compromise.
For the purposes of this survey, Compromise will be defined as follows: Sacrificing at least half of one’s
demands and accepting at least half of the demands of the opposite party in order to reach a conclusion on the
issue (or) Successfully working through the issue with the opposite party and reaching an agreement by means
of developing an alternative plan which both parties support.
1. Raising taxes for Americans with an annual income over 1 million dollars to a minimum 30 percent
effective tax rate.
Opposition Argues:
• Raising taxes in a weak economy will only make the economy suffer more.
•

Raising taxes on millionaires is punishing people for being successful and discourages them from
making money.

•

The tax rates for the top 1% of earners has already increased 12% since 1986, it would not be fair to
continue this increase.

Supporters Argue:
• The overall income for the top 1% of earners has increased 119% since 1986, meaning the income
disparity between rich and poor has increased dramatically.
• The budget deficit cannot be closed by spending cuts alone, there has to be some tax increase as well.
•

A quarter of American millionaires pay lower tax rates(less than 26.5%) than millions of middle class
earners.

Your Position (Mark one option with an X)
___Support ___Oppose ___No position
How strongly do you feel about this issue?(Mark one option with an X)
1______2______3______4______5______6______7______8______9______
Very Strongly
Neutral
Not Strongly At All
How convincing did you think the opposition’s arguments were?
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
Not Convincing At All
How convincing did you think the supporter’s arguments were?
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
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Compromise (Mark an X to the right side of the number that best represents your willingness to
compromise on this issue)
1______2______3______4______5______6______7______8______9______
Agree
Neutral
Refuse
American Jobs Act
Opposition Argues:
• The provisions of the Jobs Act are not enough to jump-start the economy.
•

Tax cuts and a stimulus package did not help the economy in 2009, why would it work now.

•

Proponents of the Jobs Act claim it can be paid for without increasing the budget deficit, but that does
not appear to be realistic.

Supporters Argue:
• The bill will put Americans back to work, therefore putting money in their pockets to stimulate the
economy.
•

The bill includes investments in repairing and rebuilding infrastructure across the country, which would
also create jobs for many Americans.

•

The bill would prohibit employers from discriminating against the unemployed and would provide a
$4,000 tax credit to employers for hiring long-term unemployed workers.

___Support
___Oppose ___No position
1______2______3______4______5______6______7______8______9______
Very Strongly
Neutral
Not Strongly At All
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
1______2______3______4______5______6______7______8______9______
Agree
Neutral
Refuse
3. Individual healthcare mandate
Opposition Argues:
• Congress is exceeding its authority by requiring people to purchase health insurance or pay a fee.
Page 14 of 17


•

The legislation is infringing on individuals liberties, by forcing people to enter into the healthcare
market against their will.
• The mandate gives the federal government too much control over the way people spend their money.
Supporters Argue:
• When individuals without healthcare coverage receive healthcare they cannot pay for, those who are
insured and the taxpayers end up paying the bill.
•

The mandate is a key part of legislation that would extend healthcare coverage to more than 30 million
uninsured people.

•

The legislation would prohibit insurance carriers from discriminating against individuals with preexisting health problems.

___Support ___Oppose ___No position
1______2______3______4______5______6______7______8______9______
Very Strongly
Neutral
Not Strongly At All
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
1______2______3______4______5______6______7______8______9______
Agree
Neutral
Refuse
4. Eliminate collective bargaining rights from public employee unions (Wisconsin bill). Opposition Argues:
• Removing collective bargaining rights may not have any effect on the budget deficit, which the
proposed law claims it will. Texas, for example, gives public employees no collective bargaining rights
and has a large budget deficit.
• Collective bargaining balances power between employer and employee, allowing employees to negotiate
for higher pay, more benefits, or better working conditions.
• By accepting the International Labor Organization's 1998 Declaration on Fundamental Principles and
Rights at Work, the US pledged 'to promote and to realize ... fundamental rights' defined in the
declaration, the first of which is 'freedom of association and the effective recognition of the right to
collective bargaining.'"
Supporters Argue:
• The law is necessary to help close the states’ $137 million budget gap.
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•
•

Public-sector employees have too much bargaining power, while most private sector employees have
little or no bargaining rights.
Taxpayers are paying for the salaries and benefits of public employees, but they do not get to be
involved when unions and politicians bargain for benefits, and have no say in how their tax dollars are
spent on public services.

___Support
___Oppose ___No position
1______2______3______4______5______6______7______8______9______
Very Strongly
Neutral
Not Strongly At All
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
1______2______3______4______5______6______7______8______9______
Very Convincing
Neutral
1______2______3______4______5______6______7______8______9______
Agree
Neutral
Refuse
Demographic Information
Please provide the following information:
Political Affiliation
Democrat
Republican
Independent
Undecided
Other
How strongly do you identify with your political party?
1______2______3______4______5______6______7______8______9______
(1)Identify Very Strongly
(5)Somewhat
(9)Do Not Identify Strongly
Are you a registered voter?
yes_____ no_____
Do you intend to vote in the upcoming election?
yes_____ no_____
How important is it that each eligible citizen participate in the election process and vote?
1______2______3______4______5______6______7______8______9______
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(1)Very Important

(5)Somewhat

Age:______
Highest level of education attained
High School or less
GED
High School Diploma
Associates Degree
Bachelors Degree
Masters Degree
Doctorate
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