IRB Approval

RESEARCH CONSENT FORM

Title of Project: Functional Assessment Study
Principal Investigator: Alan Jette, PhD

Background
Boston University Health and Disability Research Institute and YouGov are doing a research
study. This study will test a series of questions that ask about your health and functioning at two
time points.
Purpose
This purpose of this study is to test the consistency of scores generated from questions about
your health and function when administered at two different time points.
What Happens In This Research Study
You will be one of approximately 1005 subjects to be asked to participate in this study.
This research study will be conducted by YouGov on behalf of Boston University Health and
Disability Research Institute.
As a study participant you will be asked to answer questions about your functioning in daily life.
You will be asked to complete the survey on your own using the internet. This survey will be
administered at two time points 5 days apart. The first survey should take 15 minutes and the
second survey should take 30 minutes. The information we collect in this study is for research
purposes only.

Risks and Discomforts
We expect that your participation will not cause you any discomfort. There may be unknown
risks/discomforts involved. Study staff will update you in a timely way on any new information
that may affect your decision to stay in this study.
The information you provide will be kept secure and will not be disclosed to anyone but the
researchers conducting this study, except as otherwise required by law.
Potential Benefits
You will receive no direct benefit from your participation in this study. However, your

BU/BMC Institutional Review Board
IRB NUMBER: H-34328
IRB APPROVAL DATE: 11/16/2015

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RESEARCH CONSENT FORM

Title of Project: Functional Assessment Study
Principal Investigator: Alan Jette, PhD

participation may help the investigators better understand how to improve the questions they
are asking about daily life functioning of adults.
Alternatives
Your alternative is to not participate in the study.
Subject Costs and Payments
There are no costs to you for participating in this research study. As part of the YouGov panel
you will be given 1000 points to complete the first survey and 2000 points to complete the
second.
Securing Information
Information from this study may be reviewed by the Office of Human Research Protection and
the Institutional Review Board of Boston University Medical Center. Information from this study
may be used for research purposes and may be published; however, your name will not be
used in any publications.
Any and all information you provide to us will be kept secure to the extent provided by law.
Subject's Rights
By consenting to participate in this study you do not waive any of your legal rights. Giving
consent means that you have heard or read the information about this study and that you
agree to participate.
If at any time you withdraw from this study you will not suffer any penalty or lose any benefits
to which you are entitled.
You may obtain further information about your rights as a research subject by calling the
Office of the Institutional Review Board of Boston University Medical Center at 617-638-7207
The investigator or a member of the research team will try to answer all of your questions. If you

BU/BMC Institutional Review Board
IRB NUMBER: H-34328
IRB APPROVAL DATE: 11/16/2015

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RESEARCH CONSENT FORM

Title of Project: Functional Assessment Study
Principal Investigator: Alan Jette, PhD

have questions or concerns at any time while participating in this research, contact Kara Peterik
at 617-638-1995.
Right to Refuse or Withdraw
Taking part in this study is voluntary. You have the right to refuse to take part in this study. If
you decide to be in the study and then change your mind, you can withdraw from the research.
Your participation is completely up to you.
If you choose to take part, you have the right to stop at any time. If there are any new findings
during the study that may affect whether you want to continue to take part, you will be told about
them as soon as possible.
The investigator may decide to discontinue your participation without your permission
because he/she may decide that staying in the study will be bad for you, or the sponsor may
stop the study.

BU/BMC Institutional Review Board
IRB NUMBER: H-34328
IRB APPROVAL DATE: 11/16/2015

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