Rensselaer Polytechnic Institute - Light Study

Consent Form from the Participant
Rensselaer Polytechnic Institute (RPI) is conducting a pilot study into the relationship between sleep disorders and retinal anomalies. Our ultimate goal is to determine if light treatment can be used to help improve sleep efficiency and sleep quality.

You are being asked to fill out a sleep questionnaire probing your sleep quality during the past month. Participation in the study is strictly voluntary. You are free to not to fill out the questionnaire.

All data collected during the experiment will be treated as confidential. The data will be kept in an archive at the Lighting Research Center in Troy, NY. The data will not be disclosed to anyone outside the project team in such a way that you can be identified. To keep your identity seperate from our survey results, we will send you a PARTICIPANT ID number to enter when completing the questionnaire.

For further information, contact:
     Dr. Mark S. Rea
     21 Union Street, Troy, NY 12180
     Rensselaer Polytechnic Institute
     518-687-7100

     IRB Chair
     Rensselaer Polytechnic Institute
     518-276-4873

By completing and submitting this form, you agree to the following:
"I have been asked to fill out a questionnaire about my sleep quality. I have read this consent form, understand it and got satisfactory answers to all my questions and agree to participate."

First Name:

Last Name:

E-Mail Address:

Telephone:


If you are interested in participating in a color vision test as part of the study, please provide a phone number and/or e-mail address where we can contact you. Twenty dollars will be paid to those selected to participate in the color vision test. The test takes about one hour and will be conducted at Rensselaer Polytechnic Institute’s Lighting Research Center at the address listed above.

I am interested in participating in the color vision test: Yes   No