Centre for Speech, Language and the Brain

Dept. of Experimental Psychology

University of Cambridge

Downing Street

Cambridge CB2 3EB

Tel: 01223 766458

Centre for Speech, Language and the Brain

______

Language and the Brain

(CPREC Ref: 2003.19)

Research Participant Form

Thank you for your interest in participating in research with the Centre for Speech, Language and the Brain. This form should only be completed after you have read the Participant Information Sheet and the Consent Form which areattached. You will be asked to read the Information Sheet again and to sign the consent form when you come into the lab to complete the language tests. You may wish to read the enclosed Neuroimaging Information Sheet if you would also like to take part in this type of research.

We use the information in this form to ensure you are suitable for our language studies and, if you wish, for neuroimaging studies. Please read the form carefully. You do not have to answer any questions that you are uncomfortable with. If you are unsure how to answer any question please contact us for advice.

By completing this form you are agreeing for your details to be held in our secure database so that you may be contacted about studies run by the Centre for Speech, Language and the Brain, in the Department of Experimental Psychology at the University of Cambridge. You are under no obligation to take part in any studies, nor does the completion of this form imply that you give your consent to take part in further studies. Your information will not be given to any mailing lists nor used for any other purpose other than research in the CSLB.

The information you provide will be kept securely in locked filing cabinets and will be entered onto our volunteer database which is password protected and held on a secure computer network. Only authorised members of the research team in the Centre for Speech, Language and the Brain and, where relevant for your participation in the research, responsible individuals from the WBIC (Wolfson Brain Imaging Centre, University of Cambridge on the Addenbrooke’s Site) and from the MRI and MEG facilities at the CBU (MRC Cognition and Brain Sciences Unit) will have access to the information.

We will contact you by either e-mail or telephone when we wish to invite you to participate in one of our speech and language studies. If you no longer wish to participate please let us know and we will immediately remove your personal information from our records.

Please return the completed form to:

Mrs Marie Dixon, Centre for Speech, Language and the Brain, Department of Experimental Psychology, University of Cambridge, Downing Street, CambridgeCB2 3EB

Or email it to:

The medical contact Professor Edward Bullmore, Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 2QQ

11 May 2010, v2

Section 1 – Contact / Personal Information

Section 2 – Information to determine your suitability for CSLB language research

1. You are left-handed
2. Your native language is not British English
   (for our purposes, British English only includes English from the British Isles and Ireland – it does not, for example, include English spoken in Australia, America, Canada, New Zealand, India, etc.)
3. You are bilingual (i.e. you have spoken another language fluently since childhood)
4. You are colour-blind
5. You have a condition affecting language, such as dyslexia or dyspraxia, Asperger’s Syndrome, or you have problems with reading

Section 3 - Familial Handedness Questionnaire

Section 4 - Edinburgh Handedness Inventory:

• Indicate your preferences in the use of hands in the following tasks.
• Where the preference is so strong that you would never use the other hand unless forced, tick ‘RR’ (always right) or ‘LL’ (always left).
• If you are really indifferent as to which hand you use put ‘E’ (either).
• Some of the activities require both hands. In these cases the part of the task, or object, for which hand preference is wanted is indicated in brackets.
• Please try to answer all the questions, and only leave a blank if you have no experience at all of the object or task.

Section 5 – Information about your educational/work background

This information provides us with a context for your test results.

Please only complete Sections 6 and 7 if you wish to participate in fMRI (functional Magnetic Resonance Imaging) and/orMEG (Magnetoencephalogram) neuroimaging studies as well as lab-based studies.

If you do not want to take part in neuroimaging studies and would only like to do

lab-based studies please leave the remainder of this form blank.

Information about fMRI and MEG studies can be found in the Neuroimaging Information Sheet.

Section 6 – Information to determine your suitability for MRI/MEG scanning

a. Comfort Considerations

b. Neurological considerations

1. You have had an operation on your head or your brainor your heart.
2. You have had an accident that damaged your skull or brain, or you have had a serious head injury in which you lost consciousness.
3. You are epileptic or suffer from frequent sudden loss of consciousness.
4. You have or have had a neurological disorder such as stroke, brain tumour, multiple sclerosis, motor neurone disease, Parkinson’s Disease etc.

c. Metal Considerations

We will ask you about metal in more detail on the last page of this form.

1. You are unable to remove all body piercings for the duration of the scan.
2. You have undergone permanent eye lining as a cosmetic procedure.
3. You have metal implants anywhere in your body (e.g. pacemakers, aneurysm clips, cochlear implants, screws / pins / staples / clips following surgery, non-removable dental bridges - note normal dental fillings are not a problem)
4. You have ever had any accidents which may have left metal shards in your body or you have suffered eye-injury involving metal fragments.

d. Health and medication considerations

We ask you these questions because some health conditions and medication may have an effect on the data we collect, and some may mean that we are not able to include you in our scanning studies. As with all the information you provide us with, this will be kept confidential.

1. You have had meningitis.
2. You have had cancer or ongoing radiotherapy or chemotherapy treatment for cancer in the last 5 years
3. You have diabetes, heart or kidney disease, a thyroid disorder or any other serious illness or surgery
4. You have severe or uncontrolledhigh blood pressure
5. You have any of the following psychiatric disorders: bipolar disorder, schizophrenia, or psychosis.
6. You are currently taking antidepressant medication, or have taken antidepressant medication in the last six months
7. You regularly take tranquilisers
8. You are pregnant or are actively trying to get pregnant
9. You have ever taken Class A drugs (such as heroin, ecstasy, crack, cocaine)
10. You are a frequent user of Class B or C drugs (such as cannabis, amphetamines, ketamine)

Section 7 - Detailed metal screening form

Important: this form should be completed carefully by everyone who will enter the MRI or MEG suites. The following items may be extremely hazardous or produce an artefact during the scan. Please do not hesitate to ask for help in completing the list below.

1