Welcome

Welcome to the Center for Inclusive Design and Engineering (CIDE) Disability and Aging Research Recruitment Database. Thank you for volunteering to participate in our research! If this form is not accessible to you, please contact CIDE at 303-315-1280 for assistance.

Informed Consent

Title:  DARR: Disability and Aging Research Recruitment Database

Principal Investigator:  Cathy Bodine,PhD, CCC-SLP

COMIRB No:  19-1675

Version Date:  July 17, 2019

                                          

You are being asked to join this recruitment database because you have a disability, are an older adults (65+ years old), are a caregiver for someone with a disability or older adults, or are a subject matter expert in disability, aging, and/or assistive technology.


If you join the study, you will:

-  Answer questions about yourself, including demographic information and information about your health.

-  Agree to be contacted and ask if you are interested in participating in research or user experience testing at the Center for Inclusive Design and Engineering.

This database is designed to increase the number of potential participants for all research studies and user experience testing at the Center for Inclusive Design and Engineering. 


A possible risk includes breach of confidentiality of the information you provide to us. There may be risks the researchers have not thought of.


This study is not designed to benefit you directly.


Every effort will be made to protect your privacy and confidentiality by:

-  Using encrypted and password protected systems to both collect and store information about you.

-  Using your information to ask if you want to participate in research studies or user experience testing at the Center for Inclusive Design and Engineering that you may qualify for. Your information will not be provided to any outside entities or used for advertising purposes.

You have a choice about being in this database. You do not have to be in this database if you do not want to be. If you would like to withdraw from this database at any time, you may do so by sending a request via e-mail to Cathy Bodine at CIDE-Research@ucdenver.edu or via mail to Cathy Bodine at:

Attn: Cathy Bodine 

Assistive Technology Partners

UCD Auraria Campus, Hub

1224 5th Street, Campus Box 180

Denver, CO 80204


The data we collect will be used for this study but may also be important for future research. Your data may be used for future research or distributed to other researchers for future study without additional consent if information that identifies you is removed from the data.


If you have questions, you can call Cathy Bodine at 303-315-1281. You can call to ask questions at any time.


You may have questions about your rights as someone in a research study. If you have questions, you can call COMIRB (the responsible Institutional Review Board) at (303) 724-1055.


By completing this survey, you are agreeing to participate in providing information about you for storage in this recruitment database.

Name & Consent Authorization

Confirm Consent Authorization - Please confirm that you have the authority and ability to consent for yourself or that you are a legal guardian/legally authorized representative/parent who is authorized and able to consent on behalf of a participant.*
Name (Participant)*
Name of Legal Guardian/Legally Authorized Representative/Parent (if applicable)*

Please Note: For participants who cannot consent for themselves, the legal guardian, legally authorized representative, or parent must fill out this form on behalf of the participant. For legal guardians/legally authorized representatives/parents who are also a caregiver for someone with a disability or someone who is aging, you may also qualify to participate in some types of research in which we get caregiver and subject matter expert feedback. If this is the case and you are interested in being contacted to participate in our research, please feel free to fill this form out a second time for yourself.

Location & Contact Information

How did you find out about us?
If you were referred by a specific clinic or group, please put the name of the clinic/group/individual who referred you under "Other."
State of Residence
Please type the name of the city/town in which you live.
Preferred Method of Contact
(###) ###-#### - Please provide a mobile phone number if your preferred method of contact is via text.

Demographics

Which of these populations do you identify with?*
Gender
Race/Ethnicity (Primary only)
Date of Birth
Please Note: This age is calculated from your date of birth above. You may not edit this particular field. If your age does not match the age calculated, please go back and check your date of birth.

Impairment, Disability, & Technology Information

Primary Impairment
Other/Secondary Impairments (Check all others that apply)
Primary Disability/Diagnosis
Other Disabilities/Diagnoses (Check all others that apply)
Assistive Technology Devices Used (Check all that apply)

You have checked that you are not 18 years of age or older OR you are not authorized to consent for yourself. For participants who cannot consent for themselves, the legal guardian, legally authorized representative, or parent must fill out this form on behalf of the participant. Please ask your legal guardian, legally authorized representative, or parent to fill out this form on your behalf.

Subject Matter Expert

Areas of expertise (Check all that apply)