Consent for Participation in Web Survey

8% of survey complete.

Leveraged Freedom Chair (LFC) Reverse Innovation Web Survey

You have been asked to participate in a research study conducted by Benjamin Judge from the Mechanical Engineering Department at the Massachusetts Institute of Technology (M.I.T.). The purpose of the study is to determine how well the Leveraged Freedom Chair, a low cost, repairable, rugged- terrain wheelchair, meets the needs of users in different countries. The information will be used to design the next prototype and for continued design research; including Benjamin Judge's Masters thesis. You were selected as a possible participant in this study because you are considered a stakeholder that has indicated interest in the Leveraged Freedom Chair project (user, family, medical professional, business, etc). You should read the information below, and ask questions about anything you do not understand, before deciding whether or not to participate.

Participation in this study is completely voluntary. If you decide not to participate there will not be any negative consequences. Please be aware that if you decide to participate, you may stop participating at any time and you may decide not to answer any specific question.

Risks of completing the survey are psychological in nature (such as frustration) of envisioning different mobility scenarios. While no identifying information will be collected and data will be confidential, the survey provider does collect respondent time stamps.

The data collection for the project will be completed by September 2013.

By submitting this form you are indicating that you have read the description of the study, are over the age of 18, and that you agree to the terms as described.

If you have any questions, or would like a copy of this consent letter, please contact me at

Thank you in advance for your participation!
Benjamin Judge

If you feel you have been treated unfairly, or you have questions regarding your rights as a research subject, you may contact the Chairman of the Committee on the Use of Humans as Experimental Subjects, M.I.T., Room E25-143b, 77 Massachusetts Ave, Cambridge, MA 02139, phone 1-617-253-6787.

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* 1. I grant permission for the data generated from this survey to be used in the researcher's publications on this topic.

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* 2. I agree to participate in the research study survey. I understand the purpose and nature of this study and I am participating voluntarily. I understand that I can withdraw from the study at any time, without any penalty or consequences. I understand the procedures described above. My questions have been answered to my satisfaction.