Consent form for anonymous surveys

Study Title: Evaluation of young adults’ decision-making process in choosing whether to obtain a second cochlear implant

Research Investigators’ Names and Departments
Stacey Lim, Au.D., Ph.D., CCC-A
Department of Communication Disorders
Central Michigan University
(989) 774-1321
lim3s@cmich.edu

Melissa Kosky, B.S.
Audiology Graduate Student
Central Michigan University
kosky1ml@cmich.edu

Introductory Statement
You are invited to participate in a research study entitled “Evaluation of young adults’ decision-making process in choosing whether to obtain a second cochlear implant.” The research study is designed specifically for young adults aged 18-25 years old who have received the FIRST cochlear implant device before the age of 18 and who have considered getting a SECOND cochlear implant device between the ages of 18-25 years REGARDLESS of whether a cochlear implant device was obtained. Details about this study are revealed below. Please feel free to contact Dr. Stacey R. Lim if you have any questions about this project.

What is the purpose of this study?  
The purpose of this research study is to collect information through an online survey pertaining to cochlear implant usage, your perception of hearing, whether or not you chose to obtain a second cochlear implant, and your rationale for your decision to receive a second cochlear implant device or to remain unilaterally implanted.

What will I do in this study?   
You will complete a short survey lasting approximately 10-15 minutes. You will answer questions about demographic information, such as age and gender, hearing health questions, hearing aid/cochlear implant usage, perceptions of hearing, and your decision-making process related to obtaining a second cochlear implant device, pursuing other options, or maintaining your current hearing status.  

How long will it take me to do this?
This survey will take approximately 10-15 minutes to complete.

Are there any risks of participating in the study?
There are no anticipated risks associated with participating in this study.

What are the benefits of participating in the study?
This study will provide more information about the types of sources that are being used in the process to investigate cochlear implantation. Additional information related to the quality of hearing with various types of hearing devices and the expectations/perceptions that may be formulated related to device usage will be gathered and discussed in this study. There are no direct benefits for participation in this study.

Will anyone know what I do or say in this study (Confidentiality)?
No identifying information will be collected in this study. Only the investigators will have access to the survey responses. SurveyMonkey, which is being used to collect your responses, has SSL encryption and masks IP addresses, which provide anonymity.  

Will I receive any compensation for participation?
No compensation is offered for this participation in this study. Participation is strictly voluntary.

Who can I contact for information about this study?
If you have any questions or concerns about this study, please contact the lead researcher, Dr. Stacey R. Lim, at lim3s@cmich.edu or at (989) 774-1321.  
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. 
Pressing the button marked NEXT below indicates your consent to participate in this research, and affirms that you are 18 years of age or older.

 

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, 104 Foust Hall Central Michigan University, Mt. Pleasant, MI 48859.

T