INFORMED CONSENT FORM
STUDY TITLE: Teaching a robot about objects
Protocol Director: Cynthia Matuszek, Assistant Professor, EECS, UMBC
Experimenter: [you]
DESCRIPTION: You are invited to participate in a research study that aims to evaluate how easy it is to interact with a robot in different ways. As part of this study, you will be asked to give a robot instructions. You will be asked to do this task in two different settings. In the first, the robot will follow instructions quietly; in the second, it will speak its responses. With your permission, the process will be video and audio recorded, although your face will not be captured.
TIME INVOLVEMENT: Your participation will take approximately 20-25 minutes.
RISKS AND BENEFITS: We anticipate no risks with this study. We cannot and do not guarantee or promise that you will receive any benefits from this study. You might benefit from this study by learning about the state of the art in Human-Robot Interaction research, and visiting a robotics laboratory. Your decision on whether or not to participate in this study will not affect your employment.
PAYMENTS: You will receive no payment for this study.
SUBJECT'S RIGHTS: If you have read this form and have decided to participate in this project, please understand your participation is voluntary and you have the right to withdraw your consent or discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled. The alternative is to not participate. Your individual privacy will be maintained in all published and written data resulting from the study.
CONTACT INFORMATION: Questions: If you have any questions, concerns or complaints about this research, its procedures, risks andbenefits, contact the Protocol Director, Cynthia Matuszek:
Independent Contact: If you are not satisfied with how this study is being conducted, or if you have any concerns, complaints, or general questions about the research or your rights as a participant, please contact Olivia Wolfe, EECS Academic Coordinator.
I give consent to be audio recorded during these studies:
Please initial: ___Yes ___No
I give consent for recordings resulting from these studies to be used for data analyses:
Please initial: ___Yes ___No
I give consent for recordings resulting from these studies to be used for scientific presentations:
Please initial: ___Yes ___No
I give consent for recordings resulting from these studies to be used for public presentations:
Please initial: ___Yes ___No
Your signature indicates that you have read this consent form, had an opportunity to ask any questions about your participation in this research and voluntarily consent to participate.
Full name ______
Signature ______
Date ______