Consent Form

Researchers: / Professor Firstname Lastname
Department of Linguistics, University of Ottawa
Firstname Lastname
Deptartment of X
X Hospital
City, Country
Contact information: / 429 Arts Hall, 70 Laurier Ave East
Ottawa, ON K1N 6N5
Phone: (613) 562-5800 ext. XXXX
Email:

Invitation to Participate: I am invited to participate in the study ‘The articulation of Language X’s sounds’ conducted by Prof. Firstname Lastname and Firstname Lastname.

Purpose & Description of the Study: This research aims to investigate the production of sounds in Language X.

Participation: I will be asked to spend 45-60 minutes in the laboratory. The conductivity of (the amount of electricity that can go through) my glottis will be recorded and the action of my larynx will be filmed while I read a list of common words. This will allow the researchers to measure the movement of my vocal folds and my larynx (see image below). My voice will also be recorded while I read the wordlist. Before proceeding to the experiment, I will be asked a few general questions about myself (age, sex, education, language background).

In order to record the electrical resistance of my larynx, two electrodes will be placed on each side of my neck. An easily washable water-soluble gel will be applied to my skin before placing the electrodes and they will be held in place by a loose strap. A weak electrical current will then be emitted between the electrodes. This current is unnoticeable as it has a voltage comparable to a AA battery (1.5 volts).

In order to film my larynx, a beam of fiber optic (a soft and thin video cable) will be placed in my larynx through my nostril. The activity of my larynx will be film with a camera attached to this beam. Before starting the experiment, a mild anesthetic will be sprayed in my nose to prevent any discomfort. However, I might have a mild sore throat for one or two hours after the experiment.

I will be allowed to end the experiment at any time.

Risks: The equipment used in this experiment is commonly used for diagnostic purposes. The risks are negligible. They could include minor discomfort in the nasal cavity and throat, a mild sore throat and dryness in the throat. These possible effects could last for one or two hours after the experiment, but would dissipate normally.

The anaesthetic used during the experiment, xylocaine, was found that there are various possible mild side effects including rash, hives, swelling, or abnormal sensation at the site of application. There are also rare potentially serious side effects such as chest pain, continued irregular heartbeats, difficulty breathing, wheezing, hearing loss, increased sensitivity to pain, increased sensitivity to touch, lack or loss of strength, taste alteration, tremor, visual disturbance, and vomiting. In the event of these very unlikely reactions, they will be treated immediately and on site.

Confidentiality & Anonymity: I have received assurance from the researcher that the information I will share will remain strictly confidential. My name and contact information will be recorded uniquely for record-keeping purposes regarding monetary compensation. I understand that the data collected during the experiment will be used only for the purposes of investigating the research questions, i.e. how certain sounds are pronounced. My anonymity will be protected in the following manner: immediately upon completion of the experiment each participant will be assigned a code that will replace the participant’s name for all further purposes. My name will not be disclosed to any third party under any conditions (with an exception of a financial auditor from the organization that sponsors the project).

The data will be collected by Prof. Firstname Lastname and Firstname Lastname. Only Professor Firstname Lastname, Firstname Lastname and authorized research assistants will have access to the data collected from participants. Public disclosure of the data will not contain information allowing the identification of participants.

Conservation of data: The recordings collected in the study will be kept in a secure manner in cabinets in Prof. Firstname Lastname and Firstname Lastname’s office. All electronic data will be kept on password-protected computers in Professor X’s office and in the Linguistic Research Laboratory of the University of Ottawa. Only Prof. Firstname Lastname, Firstname Lastname and authorized research assistants will have access to the data.

Further use of data: The data collected during the experiment could be reanalyzed by other researchers to verify the validity of the results or compare them with the results of other studies. In such a case, my data will be transmitted in an anonymous way and my personal information will be protected.

Voluntary Participation: I am under no obligation to participate and if I choose to participate, I may withdraw from the experiment at any time. If I choose to withdraw, all data gathered until the time of withdrawal will be discarded. No negative consequences will result from either from my refusal to participate in the study or from withdrawing from the study.

Benefits: I will receive $XX upon the completion of the experiment. Should I terminate the experiment prematurely, I will be compensated at a full rate.

Acceptance: I, ______, agree to participate in the above research study conducted by ______of the Department of Linguistics, which research is under the supervision ofProfessor Firstname Lastname and Firstname Lastname).

If I have any questions about the study, I may contact the professor or the student investigator in person or at the numbers mentioned above. If I have any questions regarding the ethical conduct of this study, I may contact the Protocol Officer for Ethics in Research, University of Ottawa, Tabaret Hall, 550 Cumberland Street, Room 159, (613) 562-5841 or .

There are two copies of the consent form, one of which is mine to keep.

Participant's signature: ______Date: ______

Researcher’s signature: ______Date: ______

The project summary will be posted on the main investigator’s webpageXXX.com upon the completion of the project.

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