First Name:
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Last Name:
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Gender:
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Contact Phone Number:
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Email:
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Address:
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State:
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Zip Code:
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Would you like us to contact you about future studies?
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Yes
No
Where did you hear about this study?
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Study Flyers
Research Listserv
Social Media
Friends
UMN StudyFinder
ClinicalTrials.gov
I was in a previous study and was contacted
ENT/Audiology clinic and/or was contacted
Other
If other, please describe:
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If other, please describe:
The study lasts 18 weeks. You'll use the device for 30 minutes each day during the first 12 weeks and take part in 2 in-person and at least 6 virtual visits.
Does this sound like something you can commit to?
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Yes
No
Can you read and write in English?
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Yes
No
Do you have access to reliable internet connection and device to complete virtual video visits and electronic survey?
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Yes
No
Have you ever had any head, neck, or ear surgeries or injuries within the last 12 months?
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Yes
No
If Yes, please provide details:
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Are you currently a user of any implanted devices (e.g., pacemakers, spinal cord stimulators, cochlear implants)?
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Yes
No
If Yes, please provide details:
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Have you used hearing aids in the last 3 months?
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Yes
No
If Yes, please provide the start date of your hearing aid use:
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If Yes, please provide the estimated average duration of hearing aid use per day or per week:
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Have you stopped using your hearing aids?
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Yes
No
Have you been diagnosed with any heart conditions (e.g., bradycardia or asystole)?
* must provide value
Yes
No
Have you been diagnosed with any form of cancer?
* must provide value
Yes
No
Do you have a current ear infection or any issues affecting the middle or outer ear?
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Yes
No
If Yes, please provide details:
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Do you have any neurological conditions that may lead to loss of consciousness or seizure (e.g., epilepsy)?
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Yes
No
Are you pregnant or possibly pregnant in the next 6 months?
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Yes
No
N/A
Please list any prescription medications and doses you are currently taking:
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Do you use any benzodiazepine or sedative hypnotic medications, either regularly or as needed?
Examples include: diazepam (Valium), alprazolam (Xanax), clonazepam (Klonopin), zolpidem (Ambien), eszopiclone (Lunesta) and zaleplon (Sonata).
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Yes
No
Of those medications, were any of them NEW in the last 3 months?
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Yes
No
Of those medications, did you change dosage in the last 3 months?
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Yes
No
Did you STOP any medications or medical treatments in the past 3 months?
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Yes
No
Do you have ringing or other noises in your ears (tinnitus)?
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Yes
No
Sometimes
Have you been told you have "objective tinnitus"? Or can anyone else hear your tinnitus?
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Yes
No
How long have you experienced tinnitus? (Please indicate weeks, months, years, etc.)
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Which ear has the tinnitus?
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Right
Left
Both
Is the tinnitus constant or intermittent? (Constant = stays all the time; intermittent = comes and goes)
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Constant
Intermittent
How often in a week do you experience tinnitus?
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How long does it last each time when your tinnitus is present?
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In your own words, please describe what your tinnitus sounds like (e.g. high-pitched, low-pitched, hissing, ringing, cricket-like, ocean roar, whistle, pulsating, high-tension wire, static).
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Within the last 3 months, have you received any treatment/intervention for your tinnitus?
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Yes
No
Please describe those treatments/interventions you received. For example: Cognitive Behavioral Therapy, Sound Therapy, Implantable stimulation device, Transcranial Magnetic Stimulation, Acupuncture, etc.
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Tinnitus Questionnaire
The purpose of this questionnaire is to identify, quantify, and evaluate the difficulties that you may be experiencing because of tinnitus. Please do not skip any questions.
1 Because of your tinnitus, is it difficult for you to concentrate?
* must provide value
Yes Sometimes No
2 Does the loudness of your tinnitus make it difficult for you to hear people?
* must provide value
Yes Sometimes No
3 Does your tinnitus make you angry?
* must provide value
Yes Sometimes No
4 Does your tinnitus make you feel confused?
* must provide value
Yes Sometimes No
5 Because of your tinnitus, do you feel desperate?
* must provide value
Yes Sometimes No
6 Do you complain a great deal about your tinnitus?
* must provide value
Yes Sometimes No
7 Because of your tinnitus, do you have trouble falling to sleep at night?
* must provide value
Yes Sometimes No
8 Do you feel as though you cannot escape your tinnitus?
* must provide value
Yes Sometimes No
9 Does your tinnitus interfere with your ability to enjoy your social activities
* must provide value
Yes Sometimes No
10 Because of your tinnitus, do you feel frustrated?
* must provide value
Yes Sometimes No
11 Because of your tinnitus, do you feel that you have a terrible disease?
* must provide value
Yes Sometimes No
12 Does your tinnitus make it difficult for you to enjoy life?
* must provide value
Yes Sometimes No
13 Does your tinnitus interfere with your job or household responsibilities?
* must provide value
Yes Sometimes No
14 Because of your tinnitus, do you find that you are often irritable?
* must provide value
Yes Sometimes No
15 Because of your tinnitus, is it difficult for you to read?
* must provide value
Yes Sometimes No
16 Does your tinnitus make you upset?
* must provide value
Yes Sometimes No
17 Do you feel that your tinnitus problem has placed stress on your relationships
* must provide value
Yes Sometimes No
18 Do you find it difficult to focus your attention away from your tinnitus and on
* must provide value
Yes Sometimes No
18 Do you feel that you have no control over your tinnitus?
* must provide value
Yes Sometimes No
20 Because of your tinnitus, do you often feel tired?
* must provide value
Yes Sometimes No
21 Because of your tinnitus, do you feel depressed?
* must provide value
Yes Sometimes No
22 Does your tinnitus make you feel anxious?
* must provide value
Yes Sometimes No
23 Do you feel that you can no longer cope with your tinnitus?
* must provide value
Yes Sometimes No
24 Does your tinnitus get worse when you are under stress?
* must provide value
Yes Sometimes No
25 Does your tinnitus make you feel insecure?
* must provide value
Yes Sometimes No
View equation Scores 38-100 are eligible
GUIDELINES AND CONSENT FOR UNSECURED EMAIL CORRESPONDENCE FOR RESEARCH PARTICIPANTS
1. Purpose. By signing this form, you are agreeing that we may communicate with you through unsecured emails. This form identifies some of the risks of unsecured emails, provides guidelines for use, and documents your consent. 2. Unsecured Email Risks. Unsecured emails can be inadvertently misdirected by the sender or intentionally intercepted by third parties. The University of Minnesota cannot and does not guarantee the confidentiality of unsecured emails, nor is it responsible for unsecured emails that are lost due to technical failure during composition, transmission and/or storage. 3. Privacy and Confidentiality. Unsecured emails are not a secure method of communication. The content of an unsecured email may be viewed by any person who has access to your email account. Unsecured emails that you send us may be viewed by other staff depending on the nature and timing of your unsecured emails, and may be monitored by the University to ensure appropriate use. Unsecured emails may be viewed by your employer if you are using a work email account. Different University staff may view and process unsecured emails depending on the time of day you send them, or when your typical point of contact is not available. Communication by phone, postal mail, and secure email are considered secure. You should consider using these forms of communication. 4. Content. Unsecured emails should be used only for non-sensitive and non-urgent issues. You should limit the amount of health information in your unsecured emails to us to the minimum necessary. 5. Ending Unsecured Email Communication. This authorization does not have an expiration date. We may discontinue using unsecured emails as a means of communication with you by notifying you by unsecured email or letter. You may discontinue using unsecured emails as a means of communication by notifying us by e-mail to privacy@umn.edu or by letter to:
Health Information Privacy & Compliance Office 410 ChRC (MMC 501) 426 Church Street SE Minneapolis, MN 55455.
6. Scope. I intend for this consent to apply to the following (check the box that applies):
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The following study: Assessments of sound perception and brain activation in response to paired sound and electrical stimulation of surface ear regions
All studies at the University of Minnesota in which I participate
7. Authorizing Signature. I am the research participant or personal representative authorized to act on behalf of the participant. I have read and understand the information regarding guidelines for unsecured email correspondence and had any questions answered to my satisfaction. By signing and providing my contact information below, I agree to communicate by unsecured emails using the email address below:
Signature of research participant or research participant's personal representative.
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Printed name of research participant or research participant's personal representative.
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Email address for unsecured email communication
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Today M-D-Y
Description of personal representative's authority to act on behalf of the research participant.
e.g. self, parent, legal representative
If there is any other information you wish the researchers to know, please leave it here: