Thank you for responding to our call for volunteers to participate in our experiment.  The goal of our study is to devise fast, accurate, and non-intrusive methods for evaluating hearing in people.  This form will be shredded after the information is recorded.  If you are responding by email, the email will be deleted from the email server and retained only on the desktop computer of one researcher.  If you do not participate in the experiment, and decide against giving us your contact information, the form will be destroyed without retaining any information.  If you are responding by email, it will be deleted permanently from the server as well as from the desktop computer.

Please answer the following:

Name______________________________________    Year of birth_____________

  1. Are you able to see a ¼ inch dot on a computer monitor about 2 feet away with glasses or contact lenses?  ______ (Yes/No)
  2. Are you able to follow the dot around the screen, without moving your head? (Yes/No) ______
  3. Can you look at such a dot on a screen for up to 5 seconds without blinking, and without discomfort? (Yes/No) ______

    If you answered “NO” to any of the questions above, we cannot use you as a subject.  Thank you once again for your interest and for replying to our ad.
  4. As far as you know, do you have normal hearing in both ears? ______ (Yes/No)

    If you answered “NO” to Question 4: At this time, we are using only subjects with normal hearing in both ears.  However, we would like to keep your name and contact information so that we can re-contact you when we begin examining subjects with known hearing loss. If you think you might be interested in participating in future sessions, please ask for, and fill out, the ‘Future Participation Form’.
  5. Have you been diagnosed with any neurological problems?  This includes, but is not limited to Parkinson’s disease, traumatic brain injury, or epilepsy.   ______ (Yes/No)

    If you answered “YES” to Question 5: At this time, we are only using subjects without neurological problems. However, your participation might be invaluable at a later time, and we would like to keep your name and contact information so that we can get in touch with you at an appropriate time. If you think you might be interested in participating in future sessions, please ask for, and fill out, the ‘Future Participation Form’.

           

All your answers and contact information will be kept confidential not be disclosed to anyone without explicit permission from you.  The information in this form will be recorded in an electronic file.  There will be only three electronic copies of this file (one each with Prof. Terry Takahashi and Dr. Avinash Singh, and one copy as a backup on a CD).  No one other than the two named researchers will have access to this list.  The backup CD will be stored in a locked closet, and accessible only to Prof. Takahashi.  Your participation is voluntary.   You are free to withdraw your consent and discontinue participation at any time without penalty.

PDF version of this document to print and fill out.

If you do not qualify for the present study, sign up for the future follow-up study?
Further details and the consent form
Go back to announcement

Prof. Terry Takahashi. email Terry.
Dr. Avinash Singh. email Avinash
University of Oregon