|Rehabilitation Research and Training Center|
on Interventions for Children and Youth with TBI
National Institute on Disability and Rehabilitation Research (NIDRR)—US Department of Education
Ann Glang, Ph.D., Principal Investigator
Center on Brain Injury Research & Training, Teaching Research Institute
99 West 10th Avenue, Suite 370, Eugene, OR 97401
Informed Consent-Pilot Study
You are invited to take part in a research study to assess teachers’ (a) knowledge of traumatic brain injury (TBI) and (b) preparedness to work with these students in the classroom. The research is being conducted by Ann Glang, Ph.D. of the Center on Brain Injury Research & Training, part of Teaching Research Institute, a division of Western Oregon University (WOU). This study is funded by the U.S. Department of Education.
We want you to understand what this study is about. Please read this form and ask any questions you have before agreeing to take part in this study.
What we will ask you to do:
If you decide to take part in this study, we will ask you to complete a questionnaire. The survey will take approximately 15 minutes to complete.
What we will do with the information you provide:
Any information you provide about yourself is confidential and no individual identifying information will be associated with any response. All information you give us will be kept in secured files.
Risks and what will be done to reduce the risks:
All Teaching Research staff members are trained and experienced in working with private information. This is what we do to keep people from seeing the information you give us:
* We keep the information you give us strictly confidential.
* All contact information will be kept separate from the survey responses
* We keep all information in secured files.
* Only authorized staff of the Teaching Research Institute are allowed to see the information you give us.
* Because you are completing the survey online, absolute confidentiality cannot be guaranteed due to the limited protections of the Internet.
Benefits to you for your participation:
Your participation in this study will help identify what kind of information about TBI should be included in university coursework and in-service teacher training programs.
All surveys submitted by 11/30/2011 at 5:00PM (PST) will be entered into a random drawing to win one of five $200 cash prizes. If you would like to be entered into the drawing, please provide your contact information in the spaces provided at the end of the survey.
Right to withdraw:
Taking part in this study is completely voluntary. You are free to refuse to participate. If you decide to take part, you can quit at any time without penalty.
If you have any questions at any time about the research, please call Ann Glang (541-346-0593) or Deborah Ettel (541-346-0853) (or TDD: call 503-838-8821). You may also call toll-free, 877-872-7246.
If you have questions concerning your rights as a research subject, you may call Western Oregon University Office for Protection of Human Subjects at 503-838-9200 or email email@example.com.
Please keep this form for your records.
Thank you for your time and consideration.
I have read the above and agree to participate in this study. I understand that if I have any questions about this project I can contact the investigator at the above location or the Western Oregon University Institutional Review Board.
I understand that if I fill out and submit this survey, I am consenting to participate in this study.
PRINT COPY FOR YOUR RECORDS