CONSENT TO PARTICIPATE IN RESEARCH
Transitional Living Program Study
You are invited to participate in a research study conducted by May Flower, who is a doctoral student from the Philosophy Department at MichiganTechnologicalUniversity. Ms. Flower is conducting this study for her doctoraldissertation.Dr. Justin Time is her faculty sponsor for this project. This study is funded by the National Employability Foundation.
Your participation in this study is entirely voluntary. You should read the information below and ask questions about anything you do not understand, before deciding whether or not to participate.You are being asked to participate in this study because you are a resident of the TransitionalLivingCenter.
PURPOSE OF THE STUDY
The purpose of this study is to see how well the Transitional Living Program is working to help people with physical disabilities learn everyday skills. We hope to use what we learn from the study to make changes to the program so it will help people who are physically disabled even more than the program already does.
PROCEDURES
If you volunteer to participate in this study, we will ask you to do the following:
- We will ask you to take part in 2 to 4 tasks over the course of a total of about a 3-week length of time.
- These tasks may include: (1) keeping a diary (to be explained by the researcher), (2) answering questions about what you know, your attitudes about things, and your behavior; (3) keeping a list of your daily activities; and (4) taking quizzes on things you have learned in the program.
- Sometimes the researchers will observe you while you take part in your activities at the center.
- Some activities may be videotaped. The videorecorder will be placed in the corner of the day room and will be operated by one of the researchers.
- We will ask your permission to obtain a list of medications (and dosages) you are currently taking while in the Transitional Living Program.
POTENTIAL RISKS AND DISCOMFORTS
We expect that any risks, discomforts, or inconveniences will be minor and we believe that they are not likely to happen. If discomforts become a problem, you may discontinue your participation.
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
It is not likely that you will benefit directly from participation in this study, but the research should help us learn how to improve services for people with physical disabilitieswho have recently been discharged from the hospital for physical or occupational therapy and other assistance before moving to their own home.
This study does not include procedures that will improve your physical disability or general health.
COMPENSATION FOR PARTICIPATION
You will not receive any payment or other compensation for participation in this study. There is also no cost to you for participation.
CONFIDENTIALITY
Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. Confidentiality will be maintained by means of a code number to let Ms. Flower and Dr. Time know who you are. We will not use your name in any of the information we get from this study or in any of the research reports. When the study is finished, we will destroy the list that shows which code number goes with your name.
Information that can identify you individually will not be released to anyone outside the study. Ms. Flower will, however, use the information collected in her dissertation and other publications. We also may use any information that we get from this study in any way we think is best for publication or education. Any information we use for publication will not identify you individually.
The videotapes that we make will not be viewed by anyone outside the studyunless we have you sign a separate permission form allowing us to use them. The tapes will be destroyed three years after the end of the study, as required by the funding organization.
In case of an emergency, injury, or illness that occurs during this study, I hereby authorize the release of any and all health information to allow for medical care and treatment of my condition.
PARTICIPATION AND WITHDRAWAL
You can choose whether or not to be in this study. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may also refuse to answer any questions you donot want to answer. There is no penalty if you withdraw from the study and you will not lose any benefits to which you are otherwise entitled. The investigator may withdraw you from this research if your physician tells us that continued participation may injure your health.
IDENTIFICATION OF INVESTIGATORS
If you have any questions or concerns about the research, please feel free to contact
Ms. May FlowerDr. Justin Time
Principal InvestigatorAssociate Professor
Department of PhilosophyDepartment of Philosophy
Michigan Technological UniversityMichigan Technological University
Houghton, MI 49931Houghton, MI 49931
906-555-4444906-555-5555
RIGHTS OF RESEARCH SUBJECTS
The Michigan Tech Institutional Review Board has reviewed my request to conduct this project. If you have any concerns about your rights in this study, please contact Joanne Polzien of the Michigan Tech-IRB at 906-487-2902 or email .
I understand the procedures described above. My questions have been answered to my satisfaction, and I agree to participate in this study. I have been given a copy of this form.
______
Printed Name of Subject
______
Signature of SubjectDate
______
Signature of WitnessDate
DATE OF IRB APPROVAL: Initial______Page 1 of 3
IRB NUMBER:
PROJECT EXPIRATION DATE: