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This information will be used to clarify the nature of your face recognition problems.
1. Did you complete any of the face perception tests at this website (http://www.icn.ucl.ac.uk/facetests/). If yes, which ones and how did you score?
2. Please describe some incidents in which you have been unable to recognize others?
3. How do you typically recognize others?
4. When did you realize that you might have face recognition problems?
5. Do you believe that you have other face processing difficulties, such as recognizing facial expressions, sex, age, attractiveness or where other people are looking (eye gaze)?
6. Do you sometimes find watching movies difficult because many of the characters seem similar?
7. Do you believe that you have trouble recognizing non-facial objects such as cars, animals or places?
8. Do you have trouble navigating around your local environment?
9. Have you ever experienced head trauma, amblyopia (lazy eye), cataracts, or other serious visual problems?
10. Do you have any other neurological problems? If yes, please describe them.
11. Do you believe that other members of your family have problems with face recognition or other neurological difficulties?
12. Is there anything else that you think is relevant?
We aim to understand the perceptual, cognitive, neural and genetic factors that underlie 'face blindness', or congenital/developmental prosopagnosia. If you decide to register, your name will be added to a list of potential participants that may be asked to take part in future studies. Please note that by registering you are not obliged to participate in any research projects. For each particular study that we ask you to take part in, you will be sent an information sheet with detailed information on what the study involves (i.e., what you have to do in the study, how long it would take, where you have to go to take part, and whether there are any benefits for you, such as payments to reimburse your travel expenses). This means that over the course of the next few years we may send you information about three different studies, but that you may choose to take part in only one (or none!) of the studies, after you have read what is required in each one.
Participation in this register is entirely voluntary. If you decide to participate, you are free to withdraw from the register at any time without having to give a reason and without consequence. Your data will be destroyed when you withdraw unless you agree that the data collected prior to withdrawal can be used. Your participation does not prejudice any right to compensation, which you may have under statute or common law.
All identifiable (attributable) information is treated as strictly confidential. The only exception to this principle of confidentiality is if documents are required by law.
The investigators' aim to publish the findings in scientific journals, but you will not be identified in any publication of the results, and you can contact the researchers at any time to find out about the general results of any studies that you have taken part in.
The senior investigator monitoring this project is A/Prof. Romina Palermo, ARC Centre of Excellence in Cognition and its Disorders, and School of Psychology, University of Western Australia, Crawley, WA 6009, Australia. If you have any questions about this project please contact her via the email (Romina.Palermo@uwa.edu.au) or phone (08 6488 3256).
There are no known risks with registering. Individuals who register and participate in research projects may learn more about their ability to perceive and memorise faces and associated visual and cognitive skills.
This research is funded by the Australian Research Council Centre of Excellence in Cognition and its Disorders (CE110001021).
Thank you for your time and interest.
Approval to conduct this research has been provided by the University of Western Australia, in accordance with its ethics review and approval procedures. Any person considering participation in this research project, or agreeing to participate, may raise any questions or issues with the researchers at any time.
In addition, any person not satisfied with the response of researchers may raise ethics issues or concerns, and may make any complaints about this research project by contacting the Human Research Ethics Office at the University of Western Australia on (08) 6488 3703 or by emailing to firstname.lastname@example.org
* I have read and understood the Information and Consent details above
* I am aged over 18, or I am under the age of 18 and have approval from my parents/guardian to complete this form.
For your records please print a copy of this form before submitting it.
Telephone: (02) 9850 9599
Fax : (02) 9850 6059
Email : email@example.com
Web : www.cogsci.mq.edu.au
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