1. Couvillon, E.: Orientation and Mobility Collaboration Assessment – Consent Form 1
CONSENT FORM
Assessment of Support Resources and Internal Collaboration Between Orientation and
Mobility Instructors within the Field of Orientation and Mobility
Greetings Fellow Orientation and Mobility Colleague
My name is Elizabeth Couvillon. I am a orientation and mobility student at Stephen F.
Austin University. I am conducting research on whether Orientation and Mobility Specialists
currently have the resources and support to effectively collaborate with each other within the
field. I have a short online questionnaire that consists of 15 questions and should take no longer
than 20 minutes of your time. I would truly appreciate your participation in my study. The
information collected will ultimately be used to better the field of Orientation and Mobility and
the service our students receive. Please call me directly with any questions you might have
regarding this study: 979-450-2000. I will be happy to answer any questions you might have.
Introduction
The purpose of this form is to inform you about what it would mean for you to serve as a
participant in this research project and to provide information that may affect your decision as to
whether or not to participate in this research study. If you decide to participate in this study, this
form will also be used to record your consent.

2. Couvillon, E.: Orientation and Mobility Collaboration Assessment – Consent Form 2
You have been asked to participate in a research project studying the experiences of
collaboration among orientation and mobility specialists. The purpose of this study is to record
and analyze your reflections on the impact of the availability and effectiveness of collaboration
resources currently in the field of orientation and mobility. As an individual working as a
certified orientation and mobility specialist you were selected to be a possible participant in this
research. This study is being undertaken by faculty of the Training Program for Professionals in
Visual Impairment at Stephen F. Austin State University, is not funded, and your participation is
strictly voluntary.
What will I be asked to do?
If you agree to participate in this study, you will be asked to take part in an online
questionnaire. The questionnaire will be multiple choice and will have optional spaces to
comment. This survey is expected to take approximately 20 minutes.
What are the risks involved in this study?
There are no identified risks associated with this study. The possible difficulties
associated in this study are minimal, and are not greater than risks ordinarily encountered in daily
life. The only risks anticipated are minor discomforts typically experienced by anyone when they
are being asked to answer questions such as the possibility of mild discomfort and boredom. The

3. Couvillon, E.: Orientation and Mobility Collaboration Assessment – Consent Form 3
confidentiality of your identity and the contents of your questionnaire will be protected at all
times.
What are the possible benefits of this study?
You will receive no direct benefit from participating in this study; however, the potential
benefit of this project, once the study is completed and the results are available, is to get the
“word” out to service providers about the impact of better collaboration between orientation and
mobility specialists. This communication may occur through paper publication, state
conferences, and/or national conferences.
Do I have to participate?
No. Your participation is voluntary. You may decide not to participate or to withdraw at
any time without your current or future relations with Stephen F. Austin University being
affected.
Who will know about my participation in this research study?
This study is confidential and individual identity and information gathered will be
protected. The records of this study will be kept private. No identifiers linking you to this study

4. Couvillon, E.: Orientation and Mobility Collaboration Assessment – Consent Form 4
will be included in any sort of report that might be published. Research records will be stored
securely and only the research team will have access to the records.
If you choose to participate in this study, you will be answer an online questionnaire and
possibly answer a follow up email question with your consent. Any questionnaire or email
correspondence will be stored securely and only Dr. Okungu, and I will have access to the
correspondence. Any correspondence will be kept for three years and then erased.
Whom do I contact with questions about the research?
If you have questions regarding this study, you may contact Phoebe Okungu, Ph.D., 936-
468-5511, okungup@sfasu.edu. Additional questions may also be directed to Dr. Robbie
Steward, Chair of the SFASU Department of Human Services
Whom do I contact about my rights as a research participant?
This research study has been reviewed by SFASU’s Institutional Review Board (IRB) for
Protection of Human Subjects in Research. For research-related problems or questions regarding
your rights as a research participant, you can contact the SFASU Office of Research and
Sponsored Programs at 936-468-6606. Further questions about the IRB may be directed to the
SFASU IRB Chairperson, Dr. Pauline Sampson at (936) 468-5496 or sampsonp@sfasu.edu.

5. Couvillon, E.: Orientation and Mobility Collaboration Assessment – Consent Form 5
Signature
Please be sure you have read the above information, asked questions and received
answers to your satisfaction. You will be given a copy of the consent form for your records. By
signing this document, you consent to participate in this study.
Signature of Participant: _____________________________________ Date: ____________
Printed Name: ________________________________________________________________
Email Address to Send Questionnaire: ____________________________________________
Signature of Person Obtaining Consent: ________________________ Date: ____________
Printed Name: ________________________________________________________________
02/16/2015
Elizabeth Couvillon