We are asking you to participate in this survey about a human-like robot to assist people with mild cognitive impairments (MCI) or Alzheimer's disease and related dementias (ADRD) with their daily activities. You must be age 18 or older to participate in the study.  The information in this consent form is to help you decide if you want to be in this research study.  Please take your time reading this form and contact the researcher(s) to ask questions if there is anything you do not understand.

Why is the research being done?
The purpose of the research study is to learn your attitude and acceptance of using a human-like robot to assist the daily activities of people with Alzheimer’s disease or dementia.

What will I do in this study?
If you agree to be in this study, you will watch a video about how a robot could help care for people with Alzheimer’s disease and will answer some questions about your opinion of the robot in the video. The video is about 3 minutes long and it will take approximately 10 minutes to complete the questions. You can skip any questions that you do not want to answer.

Can I say “No”?
Being in this study is up to you. You can stop up until you submit the survey. After you submit the survey, we cannot remove your responses because we will not know which responses came from you. Either way, your decision won’t affect your relationship with any services/benefits for Alzheimer’s disease or dementia that you or your family receive.

Are there any risks to me?
Our survey is truly anonymous. We don’t know of any risks to you from being in the study.

Are there any benefits to me?
There is a possibility that you may benefit from being in the study, but there is no guarantee that will happen. Possible benefits include your improved knowledge in potential robotic technology for dementia care. Your participation may help us to learn more about how to develop robots to supplement Alzheimer’s caregiving. We hope the knowledge gained from this study will benefit others in the future.

What will happen with the information collected for this study?
The survey is anonymous, and no one will be able to link your responses back to you.  Your responses to the survey will not be linked to your computer, email address or other electronic identifiers. Please do not include your name or any other information that could be used to identify you in your survey responses.  Information provided in this survey can only be kept as secure as any other online communication. Information collected for this study will be published and possibly presented at scientific meetings.

Who can answer my questions about this research study?
If you have questions or concerns about this study, or have experienced a research related problem or injury, contact the researchers at: Xiaopeng Zhao, xzhao9@utk.edu, 865-974-7682.

For questions or concerns about your rights or to speak with someone other than the research team about the study, please contact:
Institutional Review Board
The University of Tennessee, Knoxville
1534 White Avenue
Blount Hall, Room 408
Knoxville, TN 37996-1529
Phone: 865-974-7697
Email: utkirb@utk.edu

Statement of Consent
I have read this form, been given the chance to ask questions and have my questions answered.  If I have more questions, I have been told who to contact. By clicking the “I Agree” button below, I am agreeing to be in this study. I can print or save a copy of this consent information for future reference.  If I do not want to be in this study, I can close my internet browser.
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