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Cybersecurity Research
  1. Appendix A
    1. Statement of Informed Consent
    2. Printed Name
    3. Date
    4. Signature
    5. Power of Attorney Signature (if applicable)
    6. Date

Appendix A

I have been asked to participate as a subject in a research project entitled: Effects of social technology on older adults in a residential living facility.

This project is under the direction of Dr. Jeanne Sowers and Dr. Joel Vilensky, faculty at Huntington University, as a component of the Doctor of Occupational Therapy Program’s research course, OTD 732: Research IV Design. The supervising professors can be contacted at the following numbers: Dr. Jeanne Sowers 260-702-9630 and Dr. Joel Vilensky 260-702-9621. The Huntington University Institutional Review Board Chair, Dr. Mike Rowley, can be contacted at 260-359-4277 for any questions pertaining to the research.

I understand that I am granting researchers access to certain data from my personal quarterly records including: healthcare utilization (including hospitalizations and unplanned physician visits), medication usage (including psychotropic and pain), results from the Brief Interview for Mental Status (BIMS) for cognition, and results from the (PHQ9) for depression. I understand that I will also be asked to participate in a survey with two researchers regarding my use of Sherish℠ Connect. I understand that there are very little associated risks with participating in this study. Due to researchers obtaining personal records, as well as asking survey questions, associated risks may include emotional distress.

I understand that the information obtained during this study will not be reported to anyone outside of the research team in any manner which might personally identify me. A nonidentifying number will be assigned to each individual participating in the data collection and survey for confidentiality. Data will be stored in a locked drawer and on a password-protected computer to further ensure confidentiality of participants. A report of combined and generalized results involving multiple participants will be prepared and submitted to the supervising professors and may be submitted to a journal for publishing.

My signature indicates that I received a copy of this informed consent, understand and voluntarily agree to the conditions of participation described above, and that I may withdraw from the study at any time.

Printed Name

Date

Signature

Power of Attorney Signature (if applicable)

Date

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