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Interest Form for Speech Recognition Study

Please fill out this form if you are an adult (18 years of age or older) with Cerebral Palsy and potentially interested in participating in this research project. The study will last 1-2 hours and consists of reading of single words while your speech and facial/mouth movements are recorded. Filling out this form does not commit you or the researchers to your participation in the study. Final participation in the study will be based on many factors, including severity of dysarthic speech patterns, location, availability and number of people interested in participation. You will be contacted by one of the research staff after you submit the form within a week of your form submission.

Contact information

First Name:
Last Name:
Date of Birth (MM/DD/YYYY):	(you must be 18 years old or older to participate in the study)
Street Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
E-mail:

Alternative Contact Information

If you have trouble using the phone and prefer not to use e-mail, please provide an alternative contact that can help you discuss participation in the study.

Alternative Contact:
Relationship (i.e parent, friend, gaurdian, ..):
Alternative Contact phone:
Alternative Contact e-mail:

Disabilitiy Information

Which of the following categories best describes the dominate diagnosis of your Cerebral Palsy:

How would you rate the severity of your speech impairment in terms of both people who are familar and not familar with your speech.

Most people can understand my speech the first time I say something, even people who are not familar with my speech
I often need to repeat my speech for most people to understand me, especially for people not familar with my speech
People who are familar with my speech can usually understand what I say the first time I say something
I often need to repeat my speech for people who are familar with my speech

Experience with Speech Recognition

Have you ever used speech recognition systems to enter text or control a computer system? Examples of speech recognition systems include Dragon Dictate (discontinued product), Dragon Naturally Speaking and IBM ViaVoice.

I have never tried speech recognition
I tried speech recognition, but it did not work for me
I use speech recogntion, but it is not very accurate
I use speech recogntion and it is very accurate

Demographics

National Science Foundation (NSF) and National Institutes of Health (NIH) who are supoorting this research are interested in the participation of minorties in research projects they support. The following questions allow us to report ethnicity and race statistics to our sponsors.

Ethnicity:

Hispanic or Latino
Not Hispanic or Latino
Unkown

Race:

Travel Information

Are you able to travel to University of Illinois in Champaign, Illinois (Champaign is located about 135 miles south of Chicago)