1. Welcome to My Survey

Consent Form

A Model for Prediction of IT based Assistive Technology Abandonment Among People with Disabilities

 
You are invited to participate in a web-based online survey that investigates what factors and personal characteristics impact the usage and discontinuance of assistive technology devices. This is a research project being conducted by Sara Khosravinasr, a student at department of Kinesiology and Community health at the University of Illinois at Urbana-Champaign.  

This study will take approximately 15 minutes of your time. You will be asked to complete few short questionnaires regarding your experiences with assistive technology devices and one personality related questionnaire. You will be also asked for some basic demographic questions such as age and gender and basic questions about your condition.

Your participation in this survey is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. You are free to decline to answer any particular question you do not wish to answer for any reason.

Your survey answers will be sent to a link at docs.google.com where data will be stored in a password protected electronic format. Google survey form does not collect identifying information such as your name, email address, or IP address. Therefore, your responses will remain anonymous. No one will be able to identify you or your answers, and no one will know whether or not you participated in the study.

Your participation in this research will be completely confidential and data will be averaged and reported in aggregate. Possible outlets of dissemination may be publication, presentations, research posters, or sharing within the industry or profession. In the event of publication of this research, no personally identifying information will be disclosed. To make sure that participation is confidential, please do not provide any personal identifying information on the questionnaires. The design of this study asks you to complete the survey only one time. No attempts will be made to identify you personally after the completion of this study. Although your participation in this research may not benefit you personally, your responses will provide better understanding of the reasons that are associated with assistive technology devices discontinuance. Benefits expected from this study could potentially lead to reduction in percentage of assistive technology device discontinuance and improving success rate of assistive technology device usage.

This study requires self-reflection, which may cause emotional distress for some participants. There are no other foreseeable risks involved in participating in this study beyond those encountered in day-to-day life. Remember your participation in this survey is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. You are free to decline to answer any particular question you do not wish to answer for any reason.

If you have questions or concerns at any time about the study or the procedures, you may contact my research supervisor, Dr. David Strauser via phone at 217-244-3936 or via email at strauser@illinois.edu.

If you have any concerns, complaints, or questions regarding your rights as a research participant in this study that you wish to address to someone other than the investigator, please contact the University of Illinois Institutional Review Board at 01-217-333-2670 or via email at irb@illinois.edu.

You may print a copy of this consent form for your records.

Question Title

* 1. Please select your choice below.  Clicking on the “Agree” button indicates that

·      You have read and understand the above information

·      You voluntarily agree to participate

 
8% of survey complete.

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