AVP New Volunteer Sign-up Form

The Adult Volunteer Pool keeps all volunteer information confidential. All volunteer information is amassed in a password-protected database that can only be accessed by the AVP Coordinator. Only researchers affiliated with the University of Toronto Psychology Department, who have had their studies approved by a University of Toronto Ethics Committee, as well as by the Adult Volunteer Pool, and who will be responsible for running the study in some way, will have access to information pertinent to the study being run. This information includes, but is not limited to, your name and contact information, so that a researcher can contact you about an ongoing study.

You are under no obligation to provide any information you do not wish to disclose. However, the more details you provide, the easier it is for us to properly assess your eligibility to participate in our studies. It is especially important to provide up-to-date contact information, so that we can call or e-mail you to participate in our studies.

If you have any questions or concerns, please feel free to contact the AVP Coordinator at adultpool@psych.utoronto.ca or by calling us at (416) 978-0905.

 
Name (First Last):
Address:    Apt # 
City:
Postal Code:
Primary Phone:
Alternate Phone:
E-mail:
I would prefer to be contacted by:
 
 
Date of Birth:  (mm/dd/yyyy)
Age:
Gender:
 
 
Is English your native language?
  If you answered No to the above, at what age did you learn English? 
Do you speak any other languages fluently?
Please list other fluent languages you speak: 
 
 
 
   
How many years of formal education have you completed?
What is your handedness?
What is your ethnicity?     Specify, if you wish: 
What if your marital status?                            Specify, if you wish: 
 
 
Are there times during the year when you are unavailable to participate in studies? (i.e. Do you go away for the winter/summer? Do you work specific hours?)
 
 
Vision
Please select all choices that apply to your vision.
    Normal
    Corrected to normal with glasses/contacts
    Colorblind
    Cataracts
    Glaucoma
    Macular degeneration
 
If you wish, please describe any impairments significantly affecting your vision:
 
 
Hearing
Please select all choices that apply to your hearing.
    Normal
    Corrected to normal with hearing aid
    Hearing problem, but can hear beep of microwave
    Hearing problem, and cannot hear beep of microwave
 
If you wish, please describe any impairments significantly affecting your hearing:
 
 
Neurological
Have you ever had a serious head injury? If yes, please describe (i.e. when did it occur, brief circumstances):
 
 
Have you ever lost consciousness? If yes, please describe (i.e. how, when):
 
 
Have you ever suffered a stroke?      If so, in what year(s)?       (e.g., 2003)
 
 
Medical History
Have you been hospitalized in the last 12-18 months? If yes, please describe (i.e. circumstances, is it ongoing?):
 
 
Do you have any current medical problems or are you taking any medications that we should be aware of (i.e. heart medications, high blood pressure, depression, phobias, need assistance walking)?
 
 
Have you ever been clinically diagnosed with a psychological/psychiatric illness or condition?     
 
 
If you have anything else you would like to add, please do so here:

You should receive a confirmation email from the Volunteer Coordinator approximately two business days after submitting this form.

 

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