Appendix F: Example of Informed Consent—Practitioner Study

Electromechanical Games and Exploration Behavior in Adults With Moderate Developmental Disabilities

Name(s) of Investigator:________________________

Name of Participant: __________________________

The Participant, with permission of the Parent or Guardian, has been selected to take part in a research study on the effect of electromechanical games on exploration behavior. The purpose of the study is to see if electromechanical games will encourage the Participants who have diminished interest in their surroundings to explore and interact with the game.

The Participant, with permission of the Parent or Guardian, will be given a battery-powered game for 15 minutes, 3 days per week for 6 weeks at his or her group home. His or her behavior will be recorded in writing by the Investigator of this study to see if his or her exploration behavior changes and if the game interests him or her. Behavior will be videotaped on two separate occasions.

The Participant, with permission of the Parent or Guardian, will have the choice whether or not to interact with the game. Participation is entirely voluntary and Participant or Parent or Guardian has the right to withdraw consent and discontinue participation in the study at any time without prejudice to present or future care. There is no cost for any part of the study.

No discomfort or risks are anticipated for this intervention. It is hoped that the Participant, with permission of the Parent or Guardian, will enjoy interacting with the game and may benefit from doing so by learning more about his or her environment. Information from this study will be anonymously coded to ensure confidentiality and the Participant will not be personally identified in any publication containing the results of this study.

The videotapes and written material from the study will be kept in a locked cabinet. The videotape recordings will be viewed solely by investigator(s) of the study and will be destroyed upon completion of data analysis.

The Parent or Guardian may view any videotape of the Participant which is filmed for the study.

_________________________________________, primary investigator of this study, may be reached at_____________________/___________________ (phone number/e-mail), anytime and will be available to answer any questions the Parent or Guardian may have concerning the study, the procedures, and any risks or benefits that may arise from participating in the study.

As Parent or Guardian of the previously named Participant, I give permission for him or her to participate in the research study described.

A copy of this consent form has been given to me.

Signed:

_______________ Date:___________________

Parent or Guardian

_______________ Date:___________________

Principal Investigator’s Signature

_______________ Date:___________________

Witness Signature