Walden University Assistive Technology Survey


Walden University Assistive Technology Survey

Date: Friday, April 20, 2018
Category: Member News

Questionnaire/Survey Consent Form – RESNA

Assistive technology may be a future remedy for delaying elders’ need for long-term hospitalization and promotion of independence. Little is known, about the potential utilization of assistive technology for the cognitively impaired elderly. The purpose of this questionnaire is to obtain the expert opinion about the use of assistive technology. You are invited to write a response that best characterizes how you as an expert in the field of assistive technology feel about the matter. The questionnaire will take approximately 10 to 15 minutes to complete.

Consent Form – RESNA

The researcher is inviting members of the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) to be in the study.

This form is part of “informed consent” to help you to understand this research to before to decide whether to take part.

This research is being conducted by myself Dariusz J. Ropiak, a doctoral student at Walden University.

Background Information:

The purpose of this study is to explore alternative futures of AT in aiding individuals 65 years and older who are diagnosed with Alzheimer’s and other dementia.

Data Collection Procedures:

If you agree to be in this study, you will be asked to:

  • Complete the questionnaire/survey.

Voluntary Nature of the Study:

This study is voluntary. I will respect your decision whether or not you choose to be involved. If you decide to participate in the research now, you can still change your mind later to not participate. You have the right to decline or discontinue at any time.

Risks and Benefits of Being in the Study:

Being in this type of study will not pose any risk to your safety or wellbeing. Identifying how assistive technology can help individuals 65 years and older who are diagnosed with Alzheimer’s and other dementia.


There will be no payment or compensation for the participation in the study.


Any information you provide will be kept confidential.  The researcher will not use your personal information for any purposes outside of this research project. Also, the researcher will not include your name or anything else that could identify you in the study reports. Data will be kept secure by being locked in a safe at the researcher’s house. Data will be kept for a period of at least 5 years, as required by the university.


Participants will have access to the research results after it is published.

Contacts and Questions:

You may ask any questions you have now. Or if you have questions later, you may contact the researcher via telephone 718-263-8419 or by email at dariusz.ropiak@waldenu.edu. If you want to talk privately about your rights as a participant, you can call Dr. Leilani Endicott. She is the Walden University representative who can discuss this with you. Her phone number is 612-312- 1210. Walden University’s approval number for this study is 03-20-18-0139145 and it expires on March 19th, 2019.

You may print or save a copy of the consent form for your records.

Statement of Consent:

I have read the above information and I feel I understand the study well enough to make a decision about my involvement. I understand that I am agreeing to the terms described above.

Submission of the questionnaire/survey indicates consent to participate.

To take the questionnaire/survey, go to this location on the Internet: https://www.surveymonkey.com/r/GNW6V6X

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