A Survey of Dizziness/Imbalance and Hearing Loss in Adults Living with Sickle Cell Disease

Consent for Anonymous Surveys

Study Title: Vestibular and Audiologic Profiles of Adults Living with Sickle Cell Disease

Research Investigators’ names, departments, and contact information:

Principle Investigator:
M. Dawn Nelson, Ph.D., CCC-A
Department of Communication Disorders
nelso1md@cmich.edu or (989) 506-6820

Co-Investigator:
Danielle Krupp, B.S.
Department of Communication Disorders
krupp1dm@cmich.edu or (586) 703-3205

Introductory Statement
Hearing and balance disorders in adults living with Sickle Cell Disease are important issues. Below you will find further details regarding the subject and methods of the survey. Questions regarding this survey may be directed to Dr. Nelson. Thank you for considering this study.

What is the purpose of this study?
This research study will determine the possible relationship between Sickle Cell Disease and balance and/or hearing disorders.

What will I do in this study?
In this study, you will complete a short survey regarding your general health, including the status of your hearing and balance.

How long will it take me to do this?
This survey will only take approximately 10 minutes of your time.

Are there any risks of participating in the study?
No risks are expected from this study. Although questions in this survey are straightforward, you are free to stop the survey at any time if the questions do in fact make you feel uncomfortable.

What are the benefits of participating in the study?
Current research in this area is limited. This study will help to increase knowledge within many fields of study, specifically audiology. This study will also help raise awareness for Sickle Cell Disease and the possible complications that may arise.

Will anyone know what I do or say in this study (Confidentiality)?
All identifying information will be excluded from data analysis. No identifying information will be used or disclosed in this study.

Will I receive any compensation for participation?
There is no compensation for participating in this study.

Is there a different way for me to receive this compensation or the benefits of this study?
There is no compensation for participating in this study. Benefits include the contribution to research and education within many fields of study, specifically audiology.

Who can I contact for information about this study?
With questions regarding this study or subjects’ rights, please contact Dr. Nelson at nelso1md@cmich.edu or (989) 506-6820

You are free to refuse to participate in this research project or to withdraw your consent and discontinue participation in the project at any time without penalty or loss of benefits to which you are otherwise entitled. Your participation will not affect your relationship with the institution(s) involved in this research project.

My return of this survey implies my consent to participate in this research and I have been given a second copy of this form to keep for my records. If you are not satisfied with the manner in which this study is being conducted, you may report (anonymously if you so choose) any complaints to the Institutional Review Board by calling 989-774-6401, or addressing a letter to the Institutional Review Board, 251 Foust Hall Central Michigan University, Mt. Pleasant, MI 48859.