Volunteers are needed to fill out a short questionnaire. Please read
this consent form completely and then click on the link below if you
would like to participate.

UNIVERSITY OF NORTHERN IOWA
HUMAN PARTICIPANTS REVIEW
RECRUITMENT LETTER / INFORMED CONSENT

Parent/Caregiver Reports for a Children’s Tracheostomy Themed Book

You are invited to participate in a research project conducted through
the University of Northern Iowa. The University requires that you give
your agreement to participate in this project. The following
information is provided to help you make an informed decision whether
or not to participate.

The purpose of the study is to gather information from
parents/caregivers of children who have tracheostomy tubes in order to
create a storybook that includes a child character with a
tracheostomy. If you decide to participate, you will be asked to fill
out a survey. The completed surveys will be reviewed and data obtained
may be used to influence the storyline, characters, and concepts of
the storybook. The time needed to complete the survey is estimated to
be 15 minutes.

Participating in this study may be of benefit by educating others
about children who have tracheostomies. There are minimal risks
associated with participating in this study. You may feel discomfort
in asking to provide information relating to your child who likely has
had a significant medical history. You do not have to answer questions
you do not feel comfortable with and may quit taking the survey at
anytime. Any identifying information obtained will be kept
confidential. All participants will be assigned a code which will be
kept in a locked file in the faculty advisors office. You can choose
to be put in a drawing to receive a complimentary copy of the
completed book. Information gathered from this study will be destroyed
upon completion and presentation of book. Participation in this study
is entirely voluntary. If you agree to participate in this study, you
are free to withdraw at any time without penalty. If you have a family
member who attends the Roy Eblen Speech and Hearing Clinic (RESHC),
your withdrawal from the study will not in any way affect your family
member’s status as a client in the RESHC.

If you have any questions about this research please feel free to
contact the principal investigator, Elizabeth A. Bennett or the
facility advisor, Dr. Angela Burda, at (319) 273-2496. You can also
contact the office of the Human Participants Coordinator at the
University of Northern Iowa, at (319) 273-6148, for answers to
questions about rights or research participants and the participant
review process.

By clicking on the link to the survey below, you understand that you
are fully aware of the nature and extent of your participation in this
project as stated above and the possible risks arising from it. You
hereby agree to participate in this project. You acknowledge that you
have received a copy of this consent statement, and that you are 18
years of age or older.

http://www.surveymonkey.com/s.aspx?s...dLqHDCmA_3d_3d