University of Nebraska Kearney

 Child Assent Form 

IRB #061710-4 

Title of the Research Study:  Assessing the Impact of Speech Rate and Performance in Dysarthric Speakers 

1. We would like to invite you to take part in this study.  The study is conducted by the Department of Communications Disorders at the University of Nebraska at Kearney.
   
   
2. Please talk this over with your parents before you decide whether or not to participate in this study.  Your parents will also be asked to give their permission for you to take part in this study.  But even if your parents say “yes,” you can still decide not to be in the study.
   
   
3. If you have any questions at any time, please ask.
   
   
4. In this study we will try to learn more about how changing the speed at which you speak affects the way you and other people speak.
   
   
5. Your decision to be in this study is voluntary.  You do not have to participate if you do not want to.
   
   
6. If you volunteer to be in this study, we will place a small mask over your nose, but you will be able to breathe without any problem.
   
   
7. We will also put a small plastic tube in your mouth.
   
   
8. The mask over your nose and the tube in your mouth will not hurt or even be uncomfortable for you.
   
   
9. It is possible that this study may help you and other people speak more clearly.
   
   
10. If you agree to participate in this study you will not receive a gift or money.
    
    
11. If you agree to participate in this study, you can stop at any time.   

  You are deciding whether or not to be in this study.  Signing this form (or saying “yes”) means that you have decided to participate and that all your questions about the study have been answered. You and your parents will be given a copy of this form to keep. 

_______________________________________                              ______________________________ 

Printed Name of Subject                                                          Date 

_______________________________________                              ______________________________ 

Signature of Subject                                                                 Date 

_______________________________________                              ______________________________ 

Printed Name of Witness                                                         Date 

_______________________________________                              ______________________________ 

Signature of Witness                                                                Date 

_______________________________________                              ______________________________ 

Signature of Investigator                                                          Date    

Identification of Investigators     

Principal Investigator     

Julie K. Robinson, Ph.D.  University of Nebraska at Kearney   

Office : 865-8888                     

Secondary Investigator     

Samuel Johnson, Ph.D.  University of Nebraska at Kearney      

Office: 865-9999  

Approved 06/28/10