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in partnership witH

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Invite you to join EaseVR's pilot program

 

Pilot Testing Consent Form

What is easeVR?

EaseVR is a new virtual reality experience that incorporates guided breathing exercises, mindfulness and coping skills training in an immersive virtual environment. It uses a heart rate sensor to monitor your body and use that to change the virtual experience as you use it.

For 8 days, you will be asked to use the EaseVR iPhone app and wear a Samsung GearVR headset fitted with a Samsung Galaxy S7 phone to view 3D video and audio for 10-15 minutes at a time. You will also wear a Scosche Rhythm+ heart rate sensor to track your heart rate variability.

what do i have to do in the pilot?

If you agree to be part of the research study, you will be asked to use the virtual reality program for 8 days. 

During the 8 days, you will be asked to monitor your symptom levels via the EaseVR iPhone app. In 2-3 days after completion of the 8-day program, you will be contacted via email or phone to participate in a 30 to 45-minute interview to provide your feedback on the VR experience.

will i need to pay to participate?

No, there is no cost to participate in this study. In exchange for your participation, you will receive a VR kit (Samsung GearVR, Samsung Galaxy smartphone, headphones) for use during the study period. You will be asked to return this kit at the completion of the study. You will also be asked to download the iPhone app onto your phone.

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POTENTIAL RISKS & DISCOMFORTS

appliedVR has taken steps to minimize the risks of this study. Potential side effects may include motion sickness, dizziness, eye strain, headaches or other visual abnormalities. A very small subset of patients (up to 0.025%) may experience severe symptoms (e.g. disorientation, nausea or drowsiness) upon using VR. You can remove the headset at anytime if you feel any discomfort during the experience.

Please inform appliedVR if you have a history of seizures or epilepsy, if you are prone to motion sickness, or if you have any other injuries or health problems related to your participation in this study.

CONFIDENTIALITY

Authorization to release your protected health information

Agreeing to be in this study gives appliedVR your permission to obtain, use, and share information about you for this study, and is required in order for you to take part in the study. Information about you may be obtained from your doctor and/or other health care provider involved in your care.

There are many reasons why information about you may be used or seen by the researchers or others during or after this study.  Examples include giving researchers the ability to distinguish which types of patients are most receptive to the virtual reality experience.

To keep your information safe, the researchers will keep all medical information, or any personal information that could be used to identify you in a secure file separate from your name. The data you provide will be and stored in a secure file.  Any medical related information will be stored independent from your name.

Participating in this study is completely voluntary.  Even if you decide to participate now, you may change your mind and stop at any time. You may also want to discuss it with your health care provider.

CONTACT

If you have questions about this study you may contact Jeannette Tsuei by e-mail at jtsuei@appliedvr.io or by phone at 323-332-9138.

CONSENT

Please complete the form below and check "I agree to participate in the study" to sign up. 

Name *
Name
Phone *
Phone
Please rate the general level of chronic pain you suffer from. *
Do you own an Apple iPhone (6 or later)? *
Do you have a history of seizures or epilepsy? *
Have you had any migraines in the past 6 months? *
Agree to Participate *