free iPad chance at the end of your hearing experience survey

University of Massachusetts anonymous “Listening in 2020 survey

Consent Form

Listening in 2020 Survey

This is an online consent form. At the bottom you will be asked to give your consent to participate before moving on to the survey questions.

This survey is designed to find out about people’s day-to-day experiences hearing and listening. This study is being conducted by researchers in the University of Massachusetts Amherst Department of Communication Disorders. Participation in the study is open to people living in the United States of America who are at least 40 years of age. The survey will take approximately 10 minutes to complete.

If you choose to participate, you will be asked a series of questions about various listening situations, as well as a few demographic questions and questions related to your health background.

Data collected from the survey may be used in papers and presentations related to the topic at hand. It will not be used for any commercial activity. No identifying information (such as participants’ names or dates of birth) will be taken as part of the survey. 

You will be given the opportunity to enter into a drawing for an iPad at the end of the survey. If would like to be entered into this drawing you will be directed to a separate page at the end of the survey, where you will enter your email address. This page will not be associated with your survey responses. We anticipate that the drawing will take place on 9/15/20. All email addresses will be permanently deleted by 9/30/20.    

You do not have to participate in this study if you don’t want to. If you click “I agree” below but change your mind afterwards, you may drop out/stop participating at any time. There are no penalties for doing so.

If there are questions you would like answered before participating, or any other concerns about this study or this form, you may contact the researcher (Karen Helfer) at If you have any questions concerning your rights as a research subject, you may contact the University of Massachusetts Amherst Human Research Protection Office (HRPO) at (413) 545-3428 or

By clicking “I agree to participate” below you are indicating that you are at least 40 years old, have read this consent form, and agree to participate in this research study. You are free to skip any questions that you choose.

Please print a copy of this page for your records.

  • I agree to participate
  • I do not want to participate

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