Enhancing Quality of Life for Older Adults With and Without Mild Cognitive Impairment (MCI) Through Social Engagement Over Video Technology
Phase: NA
Conditions: Aging, Mild Cognitive Impairment, Aging Well
Sponsor: University of Illinois at Urbana-Champaign

 
 
Notice of Approval: Amendment 10 
September 4, 2023  
 
Principal Investigator 
Wendy Rogers 
CC 
Raksha Mudar, Elizabeth Lydon, George Mois 
Protocol Title 
Video Technology-based Social Engagement 
Protocol Number 
22212 
Funding Source 
NIH (2 R44 AG059450-02A1) 
Review Type 
Expedited 6, 7 
Amendment Requested 
Research team update 
Status 
Active 
Risk Determination 
No more than minimal risk  
Amendment Approval Date 
September 4, 2023 
Expiration Date 
September 14, 2026 
 
 
This letter authorizes the use of human subjects in the above protocol. The University of Illinois at Urbana-
Champaign Institutional Review Board (IRB) has reviewed and approved the research study as described.  
 
The Principal Investigator of this study is responsible for: 
• 
Conducting research in a manner consistent with the requirements of the University and federal 
regulations found at 45 CFR 46. 
• 
Using the approved consent documents, with the footer, from this approved package. 
• 
Requesting approval from the IRB prior to implementing modifications. 
• 
Notifying OPRS of any problems involving human subjects, including unanticipated events, 
participant complaints, or protocol deviations. 
• 
Notifying OPRS of the completion of the study. 
 
 
 
 
 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
 
IRB Number: 22212 
 
Human Subjects Research – Protocol Form 
 
Guidelines for completing this research protocol: 
• Please submit typed applications via email. Handwritten forms and hard copy forms 
will not be accepted.  
• For items and questions that do not apply to the research, indicate as “not applicable.” 
• Provide information for all other items clearly and avoid using discipline specific 
jargon.  
• Please only include text in the provided boxes. The text boxes will expand as they are 
typed in to accommodate large amounts of text.   
Before submitting this application, ensure that the following have been completed. 
• Protocol Form is complete. 
• 
Relevant CITI modules have been completed for all members of the research team at 
www.citiprogram.org. 
• Informed consent/assent/parental permission document(s) are provided.  
• Relevant waivers and appendices are provided.  
• Recruitment materials are provided.  
• Research materials (e.g. surveys, interview guides, etc.) are provided.  
• Any relevant letters of support are provided.  
Instructions on the non-exempt review process and guidance to submitting applications, can 
be found on the OPRS website. You may also contact OPRS by email at irb@illinois.edu or 
phone at 217-333-2670. 
Submit completed applications via email to: irb@illinois.edu. 
  
 
 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
Section 1: PRINCIPAL INVESTIGATOR (PI)  
The Illinois Campus Administrative Manual allows assistant, associate, and full professors to act as 
PI. Other individuals may serve as PI after obtaining approval from the necessary party.  
Last Name:  Rogers 
First Name: Wendy  
Degree(s):  PhD 
Dept. or Unit:  Department of 
Kinesiology and Community Health 
Office Address:  3011A 
Street Address:  1206 South Fourth 
City:  Champaign 
State:  IL 
Zip Code:  61820 
Phone:  217-300-1470 
E-mail:  wendyr@illinois.edu 
Urbana-Champaign Campus Status:   
Non-visiting member of (Mark One)  
 Faculty      
  Academic Professional/Staff  
(Student Investigators cannot serve as PI) 
Training 
 Required CITI Training, Date of Completion (valid within the last 3 years), November 9, 2019 
 Additional training, Date of Completion,         
 
Section 2.  RESEARCH TEAM 
2A. Are there other investigators engaged in the research? 
 Yes (include a Research Team Form) 
 No 
2B. If yes, are any of the researchers not affiliated with Illinois? 
 Yes 
 No 
 
Section 3.  PROTOCOL TITLE 
Video Technology-based Social Engagement 
 
Section 4.  FUNDING SOURCE 
4A. Is the research funded? 
  Research is not funded and is not pending a funding decision (Proceed to Section 5). 
  Research is funded (funding decision has been made). 
  Funding decision is pending.  Funding proposal submission date:       
4B. Indicate the source of the funding.  
 University of Illinois Department, College or Campus, please specify:       
 Federal, please specify: National Institutes of Health 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
 Commercial Sponsorship & Industry1,2, please specify:       
 State of Illinois Department or Agency, please specify:       
 Other, please specify:       
4C. Sponsor-assigned grant number, if known: 2 R44 AG059450-02A1 
4D. A complete copy of the funding proposal or contract is attached. 
  Attached, please specify title: Enhancing Quality of Life for Older Adults With and Without MCI 
through Social Engagement Over Video Technology   
4E. Funding Agency Official To Be Notified of IRB Approval (if Applicable) 
Name:       
Agency:       
E-mail:       
Phone:       
 
Section 5. CONFLICTS OF INTEREST 
Please indicate below whether any investigators or members of their immediate families have any of 
the following. If the answer to any of the following items is yes, please submit the University of Illinois 
approved conflict management plan. If you have any questions about conflicts of interest, contact 
coi@illinois.edu. 
5A. Financial interest or fiduciary relationship with the research sponsor (e.g. investigator is a consultant 
for the research sponsor). 
 Yes 
 No 
5B. Financial interest or fiduciary relationship that is related to the research (e.g. investigator owns a 
startup company, and the intellectual property developed in this protocol may be useful to the 
company). 
 Yes 
 No 
5C. Two or more members of the same family are acting as research team members on this protocol.      
 Yes 
 No 
 
Section 6. SUMMARY & PURPOSE OF RESEARCH 
6A. In lay language, summarize the objective and significance of the research.  
The goal of this project is to test the efficacy of a social engagement intervention delivered 
using a video-technology called OneClick for older adults with and without mild cognitive 
impairment (MCI). Following the baseline assessment, participants will be randomized into two 
groups: Group 1 (intervention first), or Group 2 (intervention later). Group 1 will receive 8 weeks 
of the OneClick social engagement intervention, during which time Group 2 will receive no 
planned intervention. Both groups will receive an assessment at 4 weeks and another 
assessment at 8 weeks after they are enrolled in the study. Group 2 will then be rolled into the 
OneClick social engagement intervention. They will receive 8 weeks of the OneClick social 
 
1 Clarify whether or not sponsor requires specific language in the contractual agreement that impacts human subjects research  
2 Clarify whether or not the sponsor requires the protocol adhere to ICH GCP (E6) standards 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
engagement intervention, similar to Group 1, and will be assessed after four weeks and 8 weeks 
of participating in the video chat intervention. We will test the benefits of using OneClick over 8 
weeks by measuring social engagement, quality of life, and user acceptance of technology.  
 
Older adults are at risk of social isolation, and therefore, negative health and quality-of-life 
outcomes. For individuals with MCI, social activities and engagement may slow disease 
progression and the transition into dementia. Social engagement technologies offer a novel 
opportunity to connect people to enhance social interactions. OneClick’s existing platform 
connects people from across the country and world over shared interests in live, small group 
video conversations. In distinct contrast to existing social media and online chat, dating, or 
meet-up platforms, OneClick connects people virtually without the need to exchange private 
information or download an application. Users of different ages, including older adults, have 
reported positive experiences using OneClick. Our prior feasibility and usability studies have 
shown that older adults with and without MCI are interested in and will use computer 
technology and the internet for personal enjoyment. In an initial project funded by a SBIR Phase 
I (R43AG069450) grant from NIA, we optimized the OneClick platform for use by older adults 
with and without MCI (Protocol #18585 and #19145) and completed an experiential field trial to 
assess usability (Protocol #19271). The current project, funded by a SBIR Phase II grant (2 R44 
AG059450-02A1), will test the efficacy of the OneClick social engagement intervention in a larger 
randomized control trial (RCT) using a wait-list control group design.  
 
6B. Indicate if your research includes any of the following: 
 Secondary data (use of data collected for purposes other than the current research project) 
 Data collected internationally (include International Research Form) 
 Translated documents (include Certificate of Translation Form and translated documents) 
 Research activities will take place at Carle (include documentation (email or letter) from Carle stating 
that the review of your Research Services Request Form is complete)   
6C. Letters of support from outside institutions or entities that are allowing recruitment, research, or 
record access at their site(s) are attached.  
 Yes 
 Not Applicable 
 
Section 7. PROCEDURES 
7A. Select all research methods and/or data sources that apply. 
 Surveys or questionnaires,  select all that apply: 
 Paper 
 Telephone 
 Online 
 Interviews 
 Focus groups 
 Field work or ethnography 
 Standardized written, oral, or visual tests 
 Taste or smell testing 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
 Intervention or experimental manipulation 
 Exercise and muscular strength testing 
 Noninvasive procedures to collect biological specimens (e.g., hair and nail clippings, saliva, etc.) 
 Noninvasive procedures to collect physiological data (e.g., physical sensors, electrocardiography, etc.) 
 Procedures involving radiation 
 Recording audio and/or video and/or taking photographs 
 Recording other imaging 
 Materials that have already been collected or already exist, specify source of data:       
 HIPAA-protected data 
 FERPA-protected data  
 GDPR-protected data 
 Other, please specify:       
7B. List all testing instruments, surveys, interview guides, etc. that will be used in this research. 
Telephone screening DRAFT 
Modified Telephone Interview for Cognitive Status (TICS-M) 
Modified Techsage Background Questionnaire (TBSQ) 
Montreal Cognitive Assessment (MoCA) 
Geriatric Depression Scale (GDS) 
Instrumental Activities of Daily Living (IADL) 
Mobile Device Proficiency Questionnaire (MDPQ-16) 
Computer Proficiency Questionnaire (CPQ) 
Logical Memory 
Friendship Scale 
UCLA Loneliness Scale- Version 3 
Quality of Life- AD 
System Usability Scale 
Perceived Ease of Use and Usefulness 
Interpersonal Support Evaluation List 
Intention Survey 
Lubben Social Network Index 
Session Feedback Questions DRAFT 
Opinion Interview DRAFT 
Category Fluency  
Social Activity Frequency (SAQ) 
 
Drafts or final copies of all research materials are attached. 
 Yes  
7C. List approximate study dates. Date of IRB approval- August 1, 2024 
7D. What is the duration of participants’ involvement? Participants’ eligibility will be determined 
following a phone pre-screening and a video screening. If eligible, participants will be randomized into an 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
immediate social engagement intervention group or a later intervention group after a 1-hour baseline 
assessment.  
Group 1 (intervention first): Participants in this group will receive 8 weeks of the OneClick social 
engagement intervention. During this 8-week period, they will be asked to participate in 2 social 
engagement intervention sessions per week each lasting approximately 45 minutes. A mid-assessment 
will be done 4 weeks after the beginning of the intervention, and a final post-assessment after 8-weeks 
of intervention. Both assessments will take 1 hour. Participants will additionally complete a 30-45 minute 
phone interview at 4 and 8 weeks.  
 
Group 2 (intervention later): After being placed in Group 2, participants will receive no planned 
intervention in the first 8 weeks. They will complete one assessment after 4 weeks and another after 8 
weeks. Both sessions will last 1 hour. Then participants will be rolled into the OneClick social 
engagement intervention lasting 8 weeks. They will complete two additional assessments, one 4 weeks 
and the other 8 weeks after beginning the video chat intervention These assessments will last 1 hour. 
Participants will additionally complete a 30-45 minute phone interview at 12 and 16 weeks. 
 
7E. How many times will participants engage in research activities?  
Group 1 will complete three assessments: baseline; week 4 post-video chat participation; and week 8 
post-video chat participation. They will attend 16 OneClick event sessions.  
Group 2 will complete five assessments: baseline; week 4 after enrollment and before video chat 
intervention; week 8 after enrollment and before video chat intervention; week 4 post-video chat 
participation; and week 8 post-video chat participation. They will attend 16 OneClick event sessions. 
7F. Narratively describe the research procedures in the order in which they will be conducted. 
1. Phone Pre-Screening: All participants will undergo a phone screening to determine initial 
eligibility for the next step (video screening). The phone screening will gather information about 
basic demographics, living arrangements, and visual and auditory acuity. TICS-M will be 
administered to screen for global cognition. Participants who meet the initial eligibility criteria 
will be invited to participate in a video screening.  
2. Informed Consent for Video Screening: Electronic informed consent will be obtained from all 
participants using REDCap to participate in a screening session over videochat. The participants 
with MCI will have no deficits in global cognitive functioning, as determined by TICS-M. Subtle 
cognitive changes observed in these individuals do not impact their ability to provide informed 
consent; therefore, no proxy consent will be required. 
3. Video Screening: After obtaining online informed consent, participants will complete a 
background questionnaire (TSBQ). The Montreal Cognitive Assessment (MoCA) will be 
administered to assess global cognition. The Geriatric Depression Scale (GDS) will be 
administered to screen for elevated depressive symptoms. Researchers will review and 
determine final eligibility for participation. Those who meet eligibility will be invited to 
participate in the study. If they agree to participate, they will be consented for the intervention 
study before administering baseline assessment. If a participant does not qualify or prefers not 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
to participate despite being eligible, they will be thanked for their participation. The session will 
last approximately 45 minutes. All participants regardless of eligibility will be paid $15 for the 
video screening session.  
4. Informed Consent for RCT: Electronic informed consent will be obtained from all participants 
using REDCap for the RCT. Details about the study, expectations, risks, and benefits will be 
described. All questions will be clarified, and comprehension of the information will be checked 
by using the teach-back approach. The participants with MCI will have no deficits in global 
cognitive functioning. Subtle cognitive changes observed in these individuals do not impact their 
ability to provide informed consent; therefore, no proxy consent will be required. 
5. Baseline Assessment: Baseline assessment will include participant characterization measures and 
intervention outcome measures. The session will last approximately one hour. 
6. Randomization process: The randomization process is designed to achieve appropriate 
generation of the random allocation sequence and concealment of the allocation sequence. A 
researcher who is not involved in phone screening, video screening, or informed consent will 
generate the randomization list prior to the screening of the first person for the randomized, 
controlled trial. The randomization list will use computer-generated random numbers. The 
randomization list will be stratified with random permuted blocks. The stratification variable will 
be Mild Cognitive Impairment (MCI present versus absent). MCI will be defined by a MoCA score 
of 20-25. The block size will vary randomly between 4 and 6. Research personnel who perform 
phone screening, video screening, informed consent, or assessments will not be able to access 
the randomization list. After a potential participant has completed phone screening and video 
screening, has fulfilled all inclusion criteria, has demonstrated no exclusion criteria, has provided 
documented informed consent, and has completed baseline assessment, the researcher will 
unconceal the randomization assignment for the intervention: Group 1 (intervention first) versus 
Group 2 (intervention later). After assignment, the participant and the researcher who 
performed informed consent will not be blinded to group allocation.  
7. Participants in Group 2 will be told they will begin the intervention 8 weeks later and in the 
meantime will be asked to complete assessments at 4 and 8 weeks after joining the study but 
before beginning the video chat participation. Participants in Group 1 will be given information 
about the general research expectations over the next 8 weeks and will be invited to sign up for 
a technology training session to learn how to use the OneClick system. 
8. Technology training session: Participants ready to begin the video chat participation will 
complete a brief technology training session. To help schedule the technology training 
participants will be contacted by a researcher through their preferred method of 
communication. Once the technology training is scheduled, participants will be sent a reminder 
the day prior to their session.  A researcher will provide an overview of the purpose and 
functionality of the OneClick system. A help card will be mailed to the participants with 
reminders about OneClick login, event sign-up, and participation. It will list a telephone number 
and email address that can be used for questions or difficulties. One of our research team 
members will help setup the computer as needed before the 8-week trial if the participant is 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
unable to do so with remote instruction. During the training participants will also be provided 
with an opportunity to RSVP for OneClick video chat events.  
9. OneClick social engagement intervention: At least two days before starting the intervention, 
participants will receive a reminder call/email about RSVPing for the OneClick video chat session. 
If they have not, we will invite them to do so while the researcher is on the phone, in case of 
difficulties. Participants will receive an email or telephone reminder(s) about the event topic 
options for the upcoming week and encouraged to sign up for the ones that are of interest to 
them (no more than 3 reminders will be sent). We will ensure there are at least five unique 
events that cover a range of topics each week. Each event will last approximately 45 minutes. 
The event will begin with an introduction to the topic and a set of initial idea for discussion 
related to the topic. Events include a variety of topics, based on research from a previous study. 
These topics include arts and culture; nature, health, and wellness; life experiences; science and 
technology; and recreation and sports. All events include a series of pictures and discussion 
questions which have been designed to be positive and require a low memory load. Each event 
will involve a minimum of 3-4 individuals. If an event is not attended by a minimum of 3 
participants, we will have a pool of volunteers to join the event who are knowledgeable or 
interested in the topics to ensure the minimum group size for each event is maintained. Events 
will be open only to research participants and trained volunteers to ensure a safe and controlled 
environment for everyone at this stage of product testing and development. During the 
intervention, we will measure frequency of use, topic selection, discussion duration, and 
feedback comments/ratings after each event. (i.e. enjoyment, ease of use, quality of video and 
audio). If participants have not attended an event over the span of a week they will be contacted 
via their preferred method of communication to remind them to sign up for at least 2 events per 
week. Participants will be contacted for up to three weeks. If no contact has been made for three 
weeks, the participant will be dropped from the study and informed via their preferred method 
of communication.   
10. Week-4 assessment: 4 weeks after being placed into Group 1 or Group 2, participants will be 
contacted to schedule a week-4 assessment. Participants in both groups will complete measures 
related to social connectedness, loneliness, isolation, and quality of life. Group 1 will additionally 
complete measures related to system usability and perceived enjoyment of the OneClick system. 
This assessment session will take approximately 1 hour will be administered by a blinded 
assessor remotely over video or phone. Participants will be informed at the beginning of the 
assessment not to reveal their group assignment. Both groups will receive $25 for this session. 
For Group 1 only, an additional short, semi-structured interview will be administered over video 
or phone by an unblinded assessor. This will focus on ease of use, usefulness, enjoyment, 
satisfaction with the topics and conversation, suggestions for updates, and perceptions of social 
connectedness and will take 30-45 minutes. The interviews will be audiotaped and transcribed 
verbatim. Group 1 will receive $15 for completing the interview. 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
11. After this week-4 assessment, a research team member will contact participants in Group 1 to 
address any questions and issues related to the intervention to help participants remain engaged 
in the next 4-weeks of intervention.  
12. Week-8 assessment: 8 weeks after being placed into Group 1 or Group 2, participants will be 
contacted to schedule a week-8 assessment. Each group’s assessment sessions and 
compensation will be identical to week-4 assessment. This ends Group 1 participation in the 
study. They will receive a study debriefing and thanked for their time.  
13. After the week-8 assessment, a research team member will contact participants in Group 2 to 
schedule their technology training session (described in step #8). 
14. Group 2 will now begin 8 weeks of video-chat intervention 
15. Four weeks after completing video chat participation, Group 2 will complete anther assessment. 
Participants will complete measures related to social connectedness, loneliness, isolation, quality 
of life, system usability, and perceived enjoyment of the OneClick system. This assessment 
session will take approximately 1 hour and participants will receive $25. An additional short, 
semi-structured interview will be completed over video or phone. This will focus on ease of use, 
usefulness, enjoyment, satisfaction with the topics and conversation, suggestions for updates, 
and perceptions of social connectedness and will take 30-45 minutes. The interviews will be 
audiotaped and transcribed verbatim. Group 2 will receive an additional $15 for completing the 
interview. Assessors will no longer be blinded to group assignment.  
16. Following this assessment, a research team member will contact participants in Group 2 to 
address any questions and issues related to the intervention to help participants remain engaged 
in the next 4-weeks of intervention.  
17. Eight weeks after beginning video chat participation, Group 2 will complete the final assessment. 
This assessment will follow the exact same procedures and compensation as the assessment 
done after completing 4 weeks of video chat participation (#15). Group 2 will now end study. 
They will receive a study debriefing and thanked for their time.  
 
Section 8. PERFORMANCE SITES TO INCLUDE INTERNATIONAL, SCHOOL, AND COLLABORATIVE 
STUDIES 
8A. List all research sites for the protocol. For non-University of Illinois at Urbana-Champaign sites, 
describe their status of approval and provide contact information for the site. If the site has an IRB, 
note whether the IRB has approved the research or plans to defer review to the University of Illinois at 
Urbana-Champaign. 
Performances Sites 
#1 Participant's home 
#2 UIUC 
#3 CJE SeniorLife 
If there are additional performance sites, include them on an attachment and check here: 
 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
8B. Is this a multi-center study in which the Illinois investigator is the lead investigator, or the 
University of Illinois at Urbana-Champaign is the lead site? 
 Yes 
 No 
If yes, answer 8C and 8D. If no, proceed to Section 8E.  
8C. Who is the prime recipient of funding, if funded? University of Illinois at Urbana-Champaign 
8D. What is the management and communication plan for information that might be relevant to the 
protection of research subjects (e.g. unanticipated problems involving risks to subjects, interim results, 
and protocol modifications)? This is a multi-site, minimal risk clinical trial and as such will be monitored 
by an independent Safety Officer.  The Principal Investigator (PI) Dr. Wendy Rogers with support from Dr. 
Raksha Mudar will be responsible for ensuring participants’ safety on a daily basis. A Safety Officer (SO) 
has been appointed to provide data and safety monitoring oversight to monitor participant safety, 
evaluate the progress of the study, and review procedures for maintaining the confidentiality of data, 
quality of data collection, management, and analyses. James Graumlich, MD, Associate Chair for 
Research, Department of Medicine, University of Illinois College of Medicine at Peoria will serve as the 
SO. Dr. Graumlich has extensive RCT experience.  He is an internist with additional training in clinical trial 
methodology. He has 25 years of experience as a clinical trial investigator, including roles as Principal 
Investigator of federally-funded research grant protocols. Dr. Graumlich has served as a member of the 
Data Safety and Monitoring Boards for various clinical trials. 
 
No adverse events are expected given that this is a behavioral intervention study of low risk involving use 
of computer/tablet to engage in conversations with other people over a video chat platform called 
OneClick. Nevertheless, we do have a protocol in place for documenting and reporting any events to the 
safety officer (SO). 
 
Formal responses to alerts and adverse events will be followed by research staff immediately upon 
learning about such an event. When an adverse event is identified by a member of the research team, 
the event will be reported to the PI within 24 hours and recorded on the Adverse Event Form. The 
University of Illinois will be responsible for maintaining the events forms and submitting reports or 
summaries to the SO. 
8E.  If subjects will be recruited from Illinois public or private elementary or secondary schools, 
additional deadlines and procedures may apply. Criminal background clearances might be required. 
Special consideration must be given to the exclusion of protected populations. Please contact the 
School University Research Relations (researchplacements@education.illinois.edu) for more 
information. Select one: 
  Illinois schools will be used 
  Illinois schools will not be used 
 
Section 9. SUBJECT ENROLLMENT GOAL & EQUITABLE SELECTION OF SUBJECTS 
9A. For each performance site, indicate the estimated total number of participants. 
Performance Site 
# Male 
# Female 
Total 
#1 UIUC 
53 
53 
106 
#2 CJE Senior Life 
35 
35 
70 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
#3       
      
      
      
TOTALS 
88 
88 
176 
If additional performance sites are included on an attachment, check here:  
 
9B. Select all participant populations that will be recruited. 
Age: 
 Adults (18+ years old) 
 Minors (≤17 years old) 
 Specific age range, please specify: 65 and older 
Gender: 
 No targeted gender (both men and women will be recruited/included) 
 Targeted gender, please indicate: 
 Men/boys 
 Women/girls 
 Other, please specify:       
Race/Ethnicity: 
 No targeted race or ethnicity (all races and ethnicities will be recruited/included) 
 Targeted race or ethnicity, please specify:       
College Students: 
 No targeted college population 
 UIUC general student body 
 Targeted UIUC student population, provide the instructor or course information, name of the 
departmental subject pool, or other specific characteristics:       
 Students at institution(s) other than UIUC, please specify:       
Any research with students on UIUC’s campus needs to be registered with the Office of the Dean of 
Students. 
Other: 
 Inpatients 
 Outpatients 
 People who are illiterate or educationally disadvantaged 
 People who are low-income or economically disadvantaged 
 People with mental or cognitive disabilities or otherwise impaired decision-making capacities 
 Adults with legal guardians 
 People who are non-English speaking 
 People with physical disabilities 
 Pregnant or lactating women, human fetuses, and/or neonates 
 Prisoners or people with otherwise limited civil freedoms 
 Other, please specify:       
9C. Describe additional safeguards included in the protocol to protect the rights and welfare of the 
populations selected above. 
We will include older adults with Mild Cognitive Impairment (MCI).  They will be capable of providing 
Informed Consent. We will mitigate the risks of the fatigue and frustration during assessments by using 
highly trained personnel (e.g., graduate student with a minimum two years of experience working with 
older adults or a trained clinician, such as a speech-language pathologist). At UIUC, personnel will be 

  
 
 
Protocol Form 
 
 
 
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supervised by Dr. Mudar who is a clinician by training and has over two decades of experience 
conducting research involving older adults with cognitive impairment. At CJE, personnel will be 
supervised by Dr. Danilovich who is also a clinician by training with extensive experience conducting 
research involving older adults with cognitive impairment. We will make sure to provide encouragement, 
scheduled breaks, and a supportive environment for the participant. Care will be taken to minimize any 
feelings of anxiety or discomfort aroused in the participant. Before participants begin assessments, they 
will be informed that there are no right or wrong answers for the structured interviews or 
questionnaires. Participants will be informed that if they experience anxiety or discomfort at any point to 
let us know and we can stop testing immediately. It is important to note that the measures proposed for 
the study are extensively used for participant testing in the context of studies on aging.  
 
The intervention involves general conversations using the OneClick platform about topics of interest that 
promote positive reminiscing. We will offer 60 unique events (5/week) that cover a range of topics (e.g., 
pets; family traditions; baking) that promote reminiscing during conversation, known to produce positive 
affect in older adults. Participants will be encouraged to sign up for 2 events per week. They will sign up 
for events of their choosing to minimize feelings of anxiety or discomfort related to any conversation 
topic. To pre-empt negative experiences of participating in the intervention, especially in participants 
with MCI, we will provide training to use the OneClick platform, including detailed instructions about 
participation in the RCT and etiquette for participation, and quick-tip guides to make participation in the 
intervention enjoyable. We will provide printed materials for reference and contact information in case 
they require additional help. 
 
Section 10.  INCLUSION/EXCLUSION 
10A. List specific criteria for inclusion and exclusion of subjects in the study, including treatment and 
control groups. 
Inclusion criteria: Study participants will be adults who are 65 years old and older.  All participants will be 
living independently (i.e., not in assisted living or skilled nursing facilities), fluent in English, and will have 
adequate visual and auditory acuity to participate. They will have access to a computer or tablet and 
internet. They will have a Modified Telephone Interview for Cognitive Status (TICS-M) score of 22 or 
higher, Geriatric Depression Scale (GDS) score of 9 or below.  
 
Additional inclusion criteria for the MCI group include memory complaints objective memory loss 
measured by a MoCA score of 20-25, and an absence of dementia (no evidence of significant impairment 
in social or occupational functioning as determined in the background questionnaire).  
 
Exclusion criteria: Potential participants will be excluded if they have a TICS-M score lower than 22 or 
GDS score higher than 9. They will also be excluded if they have a MoCA score of 19 or less, or if they 
select “yes” to a diagnosis of Alzheimer’s disease or other dementia in the Modified TechSage 
Background Questionnaire (TSBQ).  
 

  
 
 
Protocol Form 
 
 
 
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10B. Explain how the inclusion/exclusion criteria will be assessed and by whom. If special expertise is 
required to evaluate screening responses or data, list who will make this evaluation and describe their 
training and experience. 
Inclusion/exclusion criteria will be determined by the research team using the screening forms. The 
research team has sufficient training and experience to carry out the proposed screening. 
10C. Drafts or final copies of all screening materials are attached. 
 Yes 
 Not Applicable 
10D. Describe procedures to assure equitable selection of subjects. Justify the use of the groups 
marked in Section 9B. Selection criteria that target one sex, race, or ethnic group require a clear 
scientific rationale. 
Individuals of both genders will be included with no exclusions made based on racial or ethnic factors. All 
attempts will be made to recruit equal number of male and female participants. The study will include 
adults age 65 and older both with and without a diagnosis of MCI.  
 
Section 11. RECRUITMENT 
11A. Select all recruitment procedures that will be used. 
 Student subject pool, please specify:       
 Email distribution  
 MTurk, Qualtrics Panel, or similar online population, please specify:       
 US Mail 
 Flyers/brochures 
 Website ad, online announcement (e.g. eWeek), or other online recruitment, please specify: Use of 
online announcement venues such as eWeek  
 Newspaper ad 
 Verbal announcement 
 Other, please specify: Use of Clark-Lindsey Village in-house closed circuit TV system to display 
electronic flyers. Use of quarterly “President’s Letter” including IRB-approved language from recruitment 
flyer.  
 Not applicable (secondary data only) 
11B. Drafts or final copies of all recruitment materials (including verbal scripts) are attached.  
 Yes 
 Not Applicable 
11C. For each group of participants, describe the details of the recruitment process. 
We will use our well-established multi-pronged recruitment strategies, which include word-of-mouth, 
email, and telephone scripts to members of established registries; flyers and brochures shared by 
community organizations and partners; advertisements in newspapers and newsletters; and personal 
visits to community events. All recruitment materials will be pre-approved by the IRB.  
At UIUC: Participants with and without MCI will be recruited through the I-HELP registry and Dr. Mudar’s 
registry of persons with MCI. The Human Factors and Aging Laboratory directed by Dr. Rogers is part of a 
consortium that coordinates a registry of potential older research participants through the Beckman 
Institute at UIUC called I-HELP (Illinois Health and Engagement Lifespan Project). The I-HELP registry 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
currently contains 522 individuals including individuals with a diagnosis of MCI who are interested in 
participating in university research. Dr. Mudar has a registry of individuals with MCI who are interested 
in participating in research studies. The MCI registry was developed by Dr. Mudar’s research affiliation 
and ongoing MCI studies with the Carle Neuroscience Institute, which sees approximately 100 MCI 
patients per year. Additionally, interested participants will be recruited from Carle Neuroscience Institute 
in collaboration with Dr. Daniel Llano, Staff Neurologist at Carle Hospital.  
At CJE: CJE Senior Life supports about 20,000 older adults, which includes individuals with MCI, who live 
in independent living communities. Participants with and without MCI will be recruited from the 8 
retirement community sites managed by CJE SeniorLife as well as their extensions. All sites are 
independent living. Sites in this study have been purposefully selected throughout the Chicagoland area 
to reflect a range of racial/ethnic backgrounds to maximize generalizability of findings.  Recruitment 
flyers will be placed in resident mailboxes. Additionally, residents will receive a recruitment flyer during 
community town-hall meetings. 
 
While general information about the study may be given in community settings, all formal recruitment 
will be completed via telephone to ensure privacy and individual service. The research team will 
complete encounter forms for all potential participants. The team will document all attempts to contact 
participants and will vary day and time of contact attempts if the participant is not reachable on the first 
attempt. During the recruitment pre-screening call, the research staff will follow a script to gather 
information about eligibility status and give information about the study. The research staff will clearly 
explain the time commitment, expectations for participation, and answer any questions the participant 
asks. If the person is eligible and expresses interest in enrolling, the team will schedule an appointment 
for obtaining informed consent and enrolling the participant in the study.  If the person is ineligible, staff 
will follow a script to provide this information. 
 
Section 12. REMUNERATION AND PLAN FOR DISTRIBUTION 
Refer to the University Business and Financial Policies and Procedures for further guidance on the 
compensation process and reporting requirements. 
12A. Will subjects receive inducements or rewards before, during, or after participation?  
 Yes 
 No  
If yes, complete the rest of Section 12. If no, proceed to Section 13. 
12B. Select all forms of remuneration that apply. 
 Cash, please specify amount:       
 Check, please specify amount:       
 Gift Certificate, please specify amount: All participants who complete a video screening session will 
receive $15 Amazon e-code. To promote the highest retention rate possible in the RCT, participants will 
be compensated $25 at each assessment session. There is an additional supplemental interview that will 
be given to participants currently receiving the intervention and they and will be paid $15 for each 
supplemental interview. Although participants in Group 2 will complete two additional assessments 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
(week-12 and week-16), they will be compensated for these two additional assessments. Also, 
participants will be allowed to keep their OneClick subscription for a year free of cost.  
 
 Lottery, please specify amount:       and odds:       
 Course Credit, please specify amount:       and specify equivalent alternative activity:       
 Other, please specify: Amazon e-codes will be the primary form of payment, but participants can 
request an alternative method (cash or check). 
12C. Will payment be prorated before, during, or after participation? 
 
 Yes, please specify how: In the event participants withdraw from the study early, they will receive 
payment for any assessments they have completed.  
 
 No  
12D. For each group of participants, describe the details of the remuneration plan, including how, 
when 
Payments (Amazon gift card; checks; cash) will be distributed at the end of the study, or at the end of 
participation, determined by a researcher. Participants will receive a check by mail or an Amazon E-code 
via email depending upon their preference.  
 
12E. The information listed above is provided on the relevant consent forms.  
 Yes  
 
Section 13. RISKS & BENEFITS 
13A. Describe all known risks to the participants for the activities proposed, such as risks to the 
participants’ physical well-being, privacy, dignity, self-respect, psyche, emotions, reputation, 
employability, and criminal and legal status. Risks must be described on consent forms. 
There are no specific physical or psychological risks associated with cognitive, psychological, or usability 
assessments in this research. The assessments include outcome measures that have been used 
previously with this population, including technology evaluations in persons with MCI, by the 
investigators. The primary risks of the evaluations and observations are fatigue and frustration due to 
the difficulty of some tasks. The potential risks for using a novel social engagement platform (small group 
video discussion) is hesitation in interacting with strangers.  
 
13B. Describe the steps that will be taken to minimize the risks listed above. 
To reduce the risks of fatigue and frustration, we will provide encouragement, scheduled breaks, and a 
supportive environment to make participation an interesting and beneficial experience. The events will 
be initiated by a host, a member of our research team. Afew conversational prompts will be provided to 
facilitate interactions. Also, participants will have the options to only sign up for topics of their choice. 
Our prior research has shown that older adults form new friendships (i.e., with strangers) when they co-
participate in an activity and/or share interests. OneClick, the social platform under investigation, is 
designed to connect people over shared interests.  
 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
13C. Indicate the risk level. 
 No more than minimal risk 
(The probability and magnitude of harm or discomfort anticipated for participation in the proposed 
research are not greater in and of themselves than those ordinarily encountered in daily life or during 
the performance of routine physical or psychological examinations or tests). 
 More than minimal risk (answer 13D) 
13D. If you checked that the research is more than minimal risk, describe the provisions for monitoring 
the data to ensure the safety of subjects, such as who will monitor data and how often, what criteria 
will be used to stop the research, etc. 
      
13E. Describe the expected benefits of the research to the subjects and/or to society. 
The findings from this study will have major implications on the launch and commercialization of a novel 
Internet-based social engagement platform for older adults with and without MCI. Furthermore, by 
making the platform accessible for these specific user groups, OneClick also will become more accessible 
to other, non-impaired and younger, users. This is the promise and benefit of universal, user-centered 
design. The platform could offer an easy, affordable (i.e., free) socialization avenue especially to people 
living in remote, socially-isolated areas and to those feeling socially isolated and lonely. The direct 
benefits to the participants and society outweigh any potential risks incurred through participation. 
 
13F. Weigh the risks with regard to the benefits. Provide evidence that benefits outweigh risks. 
We have taken precautions to decrease foreseeable potential risks to the participants as a result of their 
participation in this study. Overall the risks of interacting with the OneClick system, participating in the 
interview and completing the questionnaires should be minimal. A potential benefit for the participants 
is social and cognitive stimulation. These benefits outweigh the potential risks, which are minimal to 
begin with and will be further minimized by the proposed research. 
 
 
Section 14. INFORMED CONSENT PROCESS TO INCLUDE: WAIVERS, ASSENTS, ALTERATIONS, ETC. 
14A. Indicate all that apply for the consent/assent/parental permission process. 
 Written informed consent (assent) with a document signed by 
 adult subjects 
 parent(s) or guardian(s) 
 adolescents aged 8–17 years 
 Waiver of Documentation (signature) of Informed Consent (include the relevant Waiver Form) 
 adult subjects 
 parent(s) or guardian(s) 
 adolescents aged 8–17 years 
 Waiver of Informed Consent (include the relevant Waiver Form) 
 adult subjects 
 parent(s) or guardian(s) 
 adolescents aged 8–17 years 
 Alteration of Informed Consent (include the relevant Alteration Form) 
 adult subjects 
 parent(s) or guardian(s) 
 adolescents aged 8–17 years 
14B. List all researchers who will obtain consent/assent/parental permission from participants.  

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
Wendy A. Rogers, Raksha Mudar, George Mois, Elizabeth Lydon, Vincent Mathias (For more information 
of the researchers, please see attached research team form). 
14C. Describe the method for obtaining consent/assent/parental permission. Informed consent will be 
obtained online before any testing is undertaken. Details related to the study will be discussed at length. 
Any questions pertaining to the study and participation will be answered. The online informed consent 
process will be administered over REDCap with a research team member and signed electronically. 
Participants will receive a copy of the signed document for their records (either electronically or a paper 
version mailed to their home). 
14D. Describe when consent/assent/parental permission will be obtained. Informed consent for the 
video screening will be obtained before the video screening session begins. Informed consent for the RCT 
will be obtained before the baseline assessment session begins.  
14E. Will participants receive a copy of the consent form for their records?  
 Yes 
 No, if no, explain:       
14F. Indicate factors that may interfere or influence the collection of voluntary informed 
consent/assent/parental permission. 
 No known factors 
 Research will involve students enrolled in a course or program taught by a member of the research 
team 
 Research will involve employees whose supervisor(s) is/are recruiting participants 
 Participants have a close relationship to the research team 
 Other, specify any relationship that exists between the research team and participants:       
If applicable, describe the procedures to mitigate the above factors.       
14G. Copies of the consent form(s) are attached. 
 Yes 
 Not applicable 
14H. Will this project be registered as a clinical trial? 
 Yes 
 No 
If yes, effective January 21, 2019, an informed consent form must be posted on the Federal Web site 
after the clinical trial is closed to recruitment, and no later than 60 days after the last study visit.  
 
Section 15.  DEVICES & DRUGS 
Indicate if your research includes any of the following. 
 Equipment [Researchers collecting physiological data, not testing the device]  
(include Appendix A, the Research Equipment Form) 
 Devices [Researchers planning to test devices on human subjects]  
(include Appendix B, the Device Form) 
 Materials of Human Origin  
(include Appendix C, the Biological Materials Form) 
 Drugs and Biologics  
(include Appendix D, the Drug and Chemical Usage Form) 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
 MRI AT BIC To use the Beckman Institute Biomedical Imaging Center (BIC) in human subject’s 
research, you must obtain prior approval from the BIC (217.244.0446; ryambert@illinois.edu) and use 
BIC-approved screening and consent forms. Attach:  
  BIC approval 
  BIC screening form 
  BIC consent form        
 
Section 16. CONFIDENTIALITY OF DATA & PRIVACY OF PARTICIPATION 
16A. How is participant data, records, or specimens identified when received or collected by 
researchers? Identifiers include, but are not limited to, name, date of birth, email address, street 
address, phone number, audio or video recordings, and SSN. 
 No identifiers are collected 
 Direct identifiers are collected 
 Indirect identifiers (e.g. a code or pseudonym used to track participants);  
Does the research team have access to the identity key? 
 Yes 
 No 
16B. Select all methods used to safeguard research records during storage: 
 Written consent, assent, or parental permission forms are stored separately from the data 
 Data is collected or given to research team without identifiers 
 Data is recorded by research team without identifiers 
 Direct identifiers are removed from collected data as soon as possible 
 Direct identifiers are deleted and no identity key exists as soon as possible 
 Participant codes or pseudonyms are used on all data and the existing identity key is stored 
separately from the data 
 Electronic data is stored in a secure, UIUC-approved location, please specify PHI Box 
 Hard-copy data is stored in a secure location on UIUC’s campus, please specify       
 Other, please specify:       
16C. How long will identifiable data be kept? Electronic versions of the data will be archived on PHI box   
16D. Describe provisions to protect the privacy interests of subjects. Information about this research 
study will remain confidential unless we are required by law to release it. Electronic copies of the signed 
consent forms will be stored on PHI box. All participants will be assigned a participant code that is not 
related to their personal information in any way. This participant code will be used for all data collection. 
There will be one master sheet linking participant name to participant code. This sheet will be 
electronically stored on the PHI box with restricted access to the research team. Allelectronic copies of 
the data will be stored by study ID in the PHI box that only the research team has access to including the 
audio recordings. Once audio files are uploaded to the PHI box, these files will be deleted from the initial 
recording device. Strict security will be maintained to access the PHI box. No identifying information will 
be mentioned in any presentations or publications. Similar procedures at these study sites have proven 
to effectively prevent loss of confidentiality. 
16E. Describe the training and experience of all persons who will collect or have access to the data. 
Data collection will be carried out by trained personnel and access to study data will be limited to 
researchers directly involved with this research study who have been trained in methods to protect the 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
confidentiality, including IRB CITI training requirements. Workshops are held to ensure that all 
individuals involved in research keep their certification current. 
 
Section 17. DISSEMINATION OF RESULTS 
17A. List proposed forms of dissemination (e.g. journal articles, thesis, academic paper, conference 
presentation, sharing within industry, etc.).   
Results may be disseminated in the following forms: journal articles, thesis or academic papers, 
conference proceedings and presentations, and technical reports. 
17B. Will any identifiers be published, shared, or otherwise disseminated?  
 Yes 
 No  
If yes, does the consent form explicitly ask consent for such dissemination, or otherwise inform 
participants that it is required in order to participate in the study? 
 Yes 
17C. Do you intend to put de-identified data in a data repository? 
 Yes 
 No 
If yes, explain how data will be de-identified.  
We will use subject ID to substitute the real name of the participants.     
 
Section 18. INVESTIGATOR & DEPARTMENTAL ASSURANCES 
• 
I certify that the information provided in this application is complete and correct. 
• 
I certify that I will follow my IRB Approved Protocol. 
• 
I accept ultimate responsibility for the conduct of this study, the ethical performance of the 
project, and the protection of the rights and welfare of the human subjects who are directly or 
indirectly involved in this project. 
• 
I will comply with all applicable federal, state and local laws regarding the protection of human 
subjects in research. 
• 
I will ensure that the personnel performing this study are qualified and adhere to the provisions 
of this IRB-certified protocol. 
The original signature of the PI is required before this application may be processed (electronic 
signatures are acceptable). 
 
 
 
 
 
 
 
 
 
 
           8/2/22 
 
 
Principal Investigator 
 
 
 
 
 
              Date 
If the PI is not eligible to serve as PI under the Campus Administrative Manual, the applicable 
academic dean, institute director, or campus administrative officer indicates their approval of the 
researcher to act as Principal Investigator. Please note that departmental assurance only needs to be 
provided in the initial application. 
 
 

  
 
 
Protocol Form 
 
 
 
Revised: 02/07/2020 
 
 
      
 
 
 
 
 
 
Name of Authorizing Individual 
 
 
 
 
      
 
 
 
 
 
 
 
 
       
 
Signature of Authorizing Individual 
 
 
 
 
 
Date 
 
 

Online Consent Form 
Video Technology-based Social Engagement 
You are being asked to participate in a voluntary research study. The purpose of this study is to 
evaluate a video chat technology called OneClick.  In distinct contrast to existing social media 
and online chat, dating, or meet-up applications, OneClick connects people virtually for an in-
depth, meaningful conversation on topics they are passionate about. No exchange of private 
information or physical meeting is required. 
University of Illinois Urbana-Champaign 
Principal Investigator Name:  Wendy A. Rogers, Ph.D. 
Department and Institution: Kinesiology and Community Health, College of Applied Health 
Sciences, University of Illinois Urbana-Champaign 
Contact Information: Phone – (217) 300-5445  
Sponsor: The National Institute on Aging  
Why am I being asked? 
You are being invited to take part in this research study because you are 65 years or older and 
have completed the phone and video screening processes. Approximately 120 subjects may be 
involved in this research.    
Your participation in this research is voluntary. If you decide to participate, you are free to 
withdraw at any time. 
What procedures are involved?  
This study first involves completing preliminary assessments over video chat including 
information about demographics, your preferences on technology, your memory, and other 
questionnaires about your social networks, mental health, and wellbeing. This assessment is 
expected to take one hour. After completing these assessments, you will be randomized to 
participate in the intervention immediately (Group 1) or later (Group 2).  
If you are put in Group 1, you will be asked to schedule a technology training session to learn to 
use the OneClick system.   
Technology Training: Training involves viewing an instructional video that provides an overview 
of the OneClick system and steps to use it. You will then have the opportunity to ask questions 
and to explore the OneClick system. This process will take 30-60 minutes. To help schedule the 
technology training you will be contacted by a researcher through your preferred method of 
communication. Once the technology training is scheduled we will provide you reminders prior 
to the scheduled date.   

Online Consent Form 
Video chat Participation: After technology training, you will be invited to sign up for events on 
OneClick. You are expected to attend 2 video chat events of your choice per week for 8 weeks. 
Each video chat event will last 30-45 minutes. You can select which events you prefer to attend 
based on your interests and sign up via an online calendar. In the event, you will see a short 
slide presentation about the topic of interest. After the slide show, you go into a virtual 
breakout room to have a casual conversation with others about the topic. Ideas for 
conversation will be shared. You will be asked to keep confidential any information shared 
during these conversations.  
We will provide you with reminders about the events you have signed up for and links to the 
RSVP page which will allow you to select events on an ongoing basis. These reminders will 
provide you with contact information to receive any assistance that you might need with the 
RSVP process. If you do not attend any sessions for more than three weeks in a row, you may 
be withdrawn from the study.  
Week 4 Post-Video Chat Participation Assessment: At approximately 4 weeks from the start of 
your participation in events, researchers will contact you to participate in a Week 4 assessment 
conducted over OneClick. During this assessment you will complete some questionnaires. 
Assessment is expected to take 1 hour. In addition, you will be asked to complete a short 
interview over video or phone to provide your initial feedback on using the OneClick system. 
The interview is expected to take 30-45 minutes.  
Week 8 Post-Video Chat Participation Assessment: Once you have completed your 8 weeks of 
participation, researchers will contact you to complete a Week 8 assessment conducted over 
OneClick. The assessment is approximately 1 hour long. During this assessment you will 
complete some questionnaires, and you will again be asked to participate in a 30-45 minute 
interview over video or phone to provide feedback on your experience. At this point, your 
participation is complete and you will be paid, debriefed, and thanked for your participation in 
the study.  
If you are put into Group 2, you will complete two assessments at approximately 4 and 8 weeks 
from today’s date. Researchers will schedule these assessments to complete over OneClick. 
Each assessment is expected to take 1 hour. During these assessments you will complete some 
questionnaires. After 8 weeks, you will be asked to schedule a technology training session to 
learn how to use the OneClick system and will be invited to participate in 8 weeks of OneClick 
events.  
Technology Training: Training involves viewing an instructional video that provides an overview 
of the OneClick system and steps to use it. You will then have the opportunity to ask questions 
and to explore the OneClick system. This process will take 30-60 minutes. To help schedule the 
technology training you will be contacted by a researcher through your preferred method of 

Online Consent Form 
communication. Once the technology training is scheduled we will provide you reminders prior 
to the scheduled date.   
Video Chat Participation: After technology training, you will be invited to sign up for events on 
OneClick. You are expected to attend 2 video chat events of your choice per week for 8 weeks. 
Each video chat event will last 30-45 minutes. You can select which events you prefer to attend 
based on your interests and sign up via an online calendar. In the event, you will see a short 
slide presentation about the topic of interest. After the slide show, you go into a virtual 
breakout room to have a casual conversation with others about the topic. Ideas for 
conversation will be shared. You will be asked to keep confidential any information shared 
during these conversations.  
We will provide you with reminders about the events you have signed up for and links to the 
RSVP page which will allow you to select events on an ongoing basis. Furthermore, these 
reminders will provide you with contact information to receive any assistance that you might 
need with the RSVPing process. If you do not attend any sessions for more than three weeks in 
a row, you may be withdrawn from the study. If you do not attend any sessions for more than 
three weeks in a row, you may be withdrawn from the study. 
Week 4 Post-Video Chat Participation Assessment: Once you have completed 4 weeks of 
participation in events, researchers will contact you to participate in this assessment conducted 
over OneClick. During this assessment you will complete some questionnaires. Assessment is 
expected to take 1 hour. In addition, you will be asked to complete a short interview over video 
or phone to provide your initial feedback on using the OneClick system. The interview is 
expected to take 30-45 minutes.  
Week 8 Post-Video Chat Participation Assessment: Once you have completed your 8 weeks of 
participation in OneClick events, researchers will contact you to complete this assessment. The 
assessment is approximately 1 hour long. During this assessment you will complete some 
questionnaires, and you will again be asked to participate in a 30-45 minute interview over 
video or phone to provide feedback on your experience. At this point, your participation is 
complete and you will be paid, debriefed, and thanked for your participation in the study.  
What are the potential risks and discomforts? 
There are no specific physical or psychological risks associated with the assessments in this 
research. The primary risks of the assessments and observations are fatigue and frustration due 
to the difficulty of some tasks. We will provide encouragement, scheduled breaks, and a 
supportive environment to make participation an interesting and beneficial experience. There 
are no known risks of participating in a discussion other than the initial uneasiness of talking to 
strangers. However, given that the topics chosen are of mutual interests and the host will open 
the discussion, the uneasiness will be minimized. 

Online Consent Form 
Are there benefits to participating in the research? 
You are not likely to benefit directly from this study other than having an opportunity to socially 
engage in topic-centered conversations with others. The findings from this study will have 
implications for making video chat technology more accessible to older adults both with and 
without memory complaints.  
What other options are there? 
By law, participation in research is completely voluntary and may be stopped at any time 
without question or negative consequence.  Because this is not a treatment study, there are no 
alternatives to participation other than the termination of involvement in the study.  
Will my study-related information be kept confidential? 
We will use all reasonable efforts to keep your personal information confidential, but we 
cannot guarantee absolute confidentiality. When this research is discussed or published, no one 
will know that you were in the study. But, when required by law or university policy, identifying 
information may be seen or copied by: a) The Institutional Review Board that approves 
research studies; b) The Office for Protection of Research Subjects and other university 
departments that oversee human subjects research; c) University and state auditors 
responsible for oversight of research; d) Federal regulatory agencies such as the Office of 
Human Research Protections in the Department of Health and Human Services; or e) The 
National Institute on Aging.  
The data collected in this study will be de-identified and put into an archived repository and 
stored on a secure server. The link between your name and code will be kept in a password-
protected file and will be maintained by the registry coordinator. This link will be used to match 
and share your data if you are determined to be eligible to participate.  
We will ask everyone in the group discussion to respect the privacy of other participants and to 
treat anything said in the group as confidential. However, please remember there is no 
guarantee that other participants will abide by that request. 
Will I be reimbursed for any expenses or paid for my participation in this research? 
You will receive $25 for completing the assessment sessions over OneClick. You will also receive 
$15 for completing the interviews over the phone. You will receive your payment via Amazon e-
code or another method upon request. You will also have continued access to OneClick for one 
year free of cost. If you do not finish an assessment session, you will receive compensation for 
the number of sessions completed.   
Can I withdraw or be removed from the study? 
If you decide to participate, you are free to withdraw your consent and discontinue 
participation at any time. If you decide to withdraw your consent and discontinue participation, 

Online Consent Form 
the researchers will ask you to complete a very short termination visit over the phone or video 
chat. The researchers also have the right to stop your participation in this study without your 
consent if they believe it is in your best interests. 
Will data collected from me be used for any other research? 
Some of the tests that are performed in this research study are used in other studies by the 
University of Illinois Urbana-Champaign. We have established a data repository that can store 
the results of your participation in these tests with your permission to be studied in future 
projects.  Please note that the data that are stored are given a unique identification code so 
that none of the data are able to be identified.  Only the researcher and approved personnel 
will have access to the identification code key. 
Who should I contact if I have questions? 
If you have questions about this project, you may contact Wendy Rogers at 
wendyr@illinois.edu. If you have any questions about your rights as a participant in this study 
or any concerns or complaints, please contact the University of Illinois Urbana-Champaign 
Office for the Protection of Research Subjects at 217-333-2670 or via email at irb@illinois.edu. 
A copy of this consent form will be mailed or emailed to you for your records.  
I certify that I am 18 years old or older. I certify that I have read and understand the 
information in the above consent. I indicate my willingness to voluntarily participate in this 
study by typing my name in the box below. I understand that this is equivalent to signing a 
physical document. 
Participant Name (type your name here): 
Date:
SUBMIT 

Online Consent Form 
Video Technology-based Social Engagement 
You are being asked to complete a video screening to determine your eligibility for a voluntary 
research study. The purpose of this study is to investigate the benefits of using a new video 
chat technology called OneClick. This is a less than minimal risk study and there is no direct 
benefit to you for participating. 
University of Illinois Urbana-Champaign 
Principal Investigator Name:  Wendy A. Rogers, Ph.D. 
Department and Institution: Kinesiology and Community Health, College of Applied Health 
Sciences, University of Illinois Urbana-Champaign 
Contact Information: Phone – (217) 300-5445  
Sponsor: The National Institute on Aging 
Why am I being asked? 
You are being invited to take part in this research study because you are 65 years or older and 
have completed the phone screening process.   
Your participation in this research is voluntary. If you decide to participate, you are free to 
withdraw at any time. 
What procedures are involved?  
This video screening involves a brief memory test and some questionnaires. This video 
screening is expected to take 30-45 minutes. Once completed, this will determine your 
eligibility to participate in an intervention study on video technology-based social engagement. 
If you meet the eligibility for the study, you will be invited to participate in a study on video 
technology-based social engagement using OneClick. You will go through an additional 
informed consent process detailing the full study procedures. If you do not wish to participate, 
you are able to decline participation at any point. You will be paid for your time in the study. 
In some cases, eligibility for the study will need to be reviewed by the Principal Investigators 
and research team. If this is the case, at the end of the video screening we will let you know 
that we need time to determine eligibility. We will follow-up with you over phone or email once 
your eligibility is determined.   
If you are not eligible for the study, you will be paid and asked if you would like to be added to 
our database for future study participation. 
What are the potential risks and discomforts? 
There are no specific physical or psychological risks associated with the assessments in this 

Online Consent Form 
research. The primary risks of the assessments and observations are fatigue and frustration due 
to the difficulty of some tasks. We will provide encouragement, breaks, and a supportive 
environment to make participation an interesting and beneficial experience. There are no 
known risks of participating in the video screening. 
Are there benefits to participating in the research? 
You are not likely to benefit directly from this video screening study. The findings from this 
screening will determine if you are eligible to participate in the intervention study.   
What other options are there? 
By law, participation in research is completely voluntary and may be stopped at any time 
without question or negative consequence.  Because this is not a treatment study, there are no 
alternatives to participation other than the termination of involvement in the study.  
Will my study-related information be kept confidential? 
We will use all reasonable efforts to keep your personal information confidential, but we 
cannot guarantee absolute confidentiality. When this research is discussed or published, no one 
will know that you were in the study. But, when required by law or university policy, identifying 
information may be seen or copied by: a) The Institutional Review Board that approves 
research studies; b) The Office for Protection of Research Subjects and other university 
departments that oversee human subjects research; c) University and state auditors 
responsible for oversight of research; d) Federal regulatory agencies such as the Office of 
Human Research Protections in the Department of Health and Human Services; or e) The 
National Institute on Aging.  
The data collected in this study will be de-identified and put into an archived repository and 
stored on a secure server. The link between your name and code will be kept in a password-
protected file and will be maintained by the registry coordinator. This link will be used to match 
and share your data if you are determined to be eligible to participate.  
Will I be reimbursed for any expenses or paid for my participation in this research? 
You will be compensated $15 for your participation in the video screening via Amazon E-Code 
or an alternative method upon request.  
Can I withdraw or be removed from the study? 
If you decide to participate, you are free to withdraw your consent and discontinue 
participation at any time. The researchers also have the right to stop your participation in this 
study without your consent if they believe it is in your best interests. 

Online Consent Form 
Will data collected from me be used for any other research? 
Some of the tests that are performed in this research study are used in other studies by the 
University of Illinois Urbana-Champaign. We have established a data repository that can store 
the results of your participation in these tests with your permission to be studied in future 
projects. Please note that the data that are stored are given a unique identification code so that 
none of the data are able to be identifiable. Only researchers and approved personnel will have 
access to the identification code key. 
Who should I contact if I have questions? 
If you have questions about this project, you may contact Wendy Rogers at 
wendyr@illinois.edu. If you have any questions about your rights as a participant in this study 
or any concerns or complaints, please contact the University of Illinois Urbana-Champaign 
Office for the Protection of Research Subjects at 217-333-2670 or via email at irb@illinois.edu. 
A copy of this consent form will be mailed or emailed to you for your records. 
I certify that I am 18 years old or older. I certify that I have read and understand the 
information in the above consent. I indicate my willingness to voluntarily participate in this 
study by typing my name in the box below. I understand that this is equivalent to signing a 
physical document. 
Participant Name (type your name here): 
Date:
SUBMIT 

 
 
Research Team  
 
 
1 of 18 
                             
 
Revised: 4/19/2021 
 
For Listing Additional Researchers who are Involved in the Project 
All forms must be typewritten and submitted via email to irb@illinois.edu. 
 
When to use this form: If there are collaborating researchers participating in a research study, including 
those from other institutions, complete this form by listing all collaborating researchers. Include all 
persons who will be: 1) directly responsible for project oversight and implementation, 2) recruitment, 3) 
obtaining informed consent, or 4) involved in data collection, analysis of identifiable data, and/or follow-
up. Please copy and paste text fields to add additional research team members.  
Note:  
• 
Changes made to the Principal Investigator require a revised Protocol Form and an Amendment 
Form. 
• 
A complete Research Team form with all research team members included needs to be submitted 
every time the research team is updated.  
 
Section 1. PROTOCOL INFORMATION 
1A. Principal Investigator: Dr. Wendy Rogers 
1B. Protocol Number: 22212 
1C. Project Title: Video Technology-based Social Engagement 
 
Section 2. ADDITIONAL INVESTIGATORS 
 
Full Name: Raksha Mudar 
Degree: PhD 
Dept. or Unit: Applied 
Health Sciences - SHS 
Professional Email: raksha@illinois.edu 
Phone: 217-333-4718 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 07/29/2022 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify: project oversight 
If administering biomedical study procedure (e.g., blood draws, scans, depression index, etc.), please 
specify the procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       

 
 
Research Team  
 
 
2 of 18 
                             
 
Revised: 4/19/2021 
Date added to research team:   07/26/2021                               Date removed from research team:         
 
Full Name: Elizabeth Lydon 
Degree: M.S. 
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: elydon2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 06/29/2021 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                            Date removed from research team:         
 
 
Full Name: Shraddha Shende 
Degree: M.S. 
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: sshende2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 8/27/2022 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   

 
 
Research Team  
 
 
3 of 18 
                             
 
Revised: 4/19/2021 
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                            Date removed from research team:         
 
Full Name: Madina Khamzina 
Degree: MPH 
Dept. or Unit: Applied 
Health Sciences- 
Community Health 
Professional Email: madinak2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 06/30/2020 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                     Date removed from research team:   12/15/2021 
 
Full Name: Allura Lothary 
Degree: PhD 
Dept. or Unit: Applied 
Health Sciences- 
Community Health 
Professional Email: alothary@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify: Postdoctoral Research Associate 
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 10/05/2020 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       

 
 
Research Team  
 
 
4 of 18 
                             
 
Revised: 4/19/2021 
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                     Date removed from research team:   09/10/2021 
 
Full Name: Saahithya Gowrishankar 
Degree: B.S. 
Dept. or Unit: Applied 
Health Sciences- 
Community Health 
Professional Email: sg14@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 05/29/2019 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                      Date removed from research team:   04/08/2022 
 
Full Name: Sarah Jones 
Degree:  
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: sarahej3@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/01/2022 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 

 
 
Research Team  
 
 
5 of 18 
                             
 
Revised: 4/19/2021 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                            Date removed from research team:         
 
Full Name: Ari Sovsic 
Degree:  
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: asovsi2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/28/2019 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   08/31/2021                      Date removed from research team:   05/03/2022 
 
 
Full Name: Kelly Kepka 
Degree:  
Dept. or Unit: Applied 
Health Sciences- MCB 
Professional Email: kepka2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 01/07/2021 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 

 
 
Research Team  
 
 
6 of 18 
                             
 
Revised: 4/19/2021 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                     Date removed from research team:   05/06/2022 
 
Full Name: Margaret Danilovich 
Degree: PhD 
Dept. or Unit:  
Professional Email: margaret.danilovich@cje.net 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify: CJE SeniorLife 
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify: CJE SeniorLife Senior Director of Research 
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 9/13/2021 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                            Date removed from research team:         
 
Full Name: Rachel Lessem 
Degree: PhD 
Dept. or Unit:  
Professional Email: Rachel.Lessem@cje.net 
Phone: 773-508-1151 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify: CJE SeniorLife 
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify: CJE SeniorLife Research and Evaluation Associate 
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 9/13/2021 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       

 
 
Research Team  
 
 
7 of 18 
                             
 
Revised: 4/19/2021 
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   07/26/2021                            Date removed from research team:         
 
 
Full Name: George Mois  
Degree: PhD 
Dept. or Unit:  
Professional Email: mois@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify: CJE SeniorLife Research and Evaluation Associate 
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 02/05/2020 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   08/31/2021                            Date removed from research team:         
 
 
Full Name: Noah Olivero  
Degree:  
Dept. or Unit:  
Professional Email: noahto2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/25/2021 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       

 
 
Research Team  
 
 
8 of 18 
                             
 
Revised: 4/19/2021 
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   08/31/2021                            Date removed from research team:         
 
Full Name: John Marendes  
Degree:  
Dept. or Unit:  
Professional Email: marendes@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 09/07/2021 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   01/31/2022                            Date removed from research team:         
 
 
Full Name: Nithya Anand  
Degree:  
Dept. or Unit:  
Professional Email: nithyas2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify: CJE SeniorLife Research and Evaluation Associate 
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/25/2021 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       

 
 
Research Team  
 
 
9 of 18 
                             
 
Revised: 4/19/2021 
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   01/31/2022                            Date removed from research team:         
 
Full Name: Kelly Trevillian 
Degree:       
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: kellynt2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 03/02/2020 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, depression index, etc.), please 
specify the procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   02/07/2022                      Date removed from research team:   05/06/2022 
 
Full Name: Alexandra Trekas 
Degree:       
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: trekas2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/29/2020 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       

 
 
Research Team  
 
 
10 of 18 
                             
 
Revised: 4/19/2021 
If administering biomedical study procedure (e.g., blood draws, scans, depression index, etc.), please 
specify the procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   02/07/2022                           Date removed from research team:    
 
Full Name: Vince Mathias 
Degree:  
Dept. or Unit:  
Professional Email: vmathias@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 02/09/2022 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   02/09/2022                            Date removed from research team:         
 
Full Name: Nathan Fensterheim 
Degree:  
Dept. or Unit:  
Professional Email: nef4@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 02/09/2022 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       

 
 
Research Team  
 
 
11 of 18 
                             
 
Revised: 4/19/2021 
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   01/31/2022                         Date removed from research team:   8/22/2022 
 
Full Name: Sharbel Yako 
Degree:  
Dept. or Unit:  
Professional Email: syako2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 02/09/2022 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   01/31/2022                            Date removed from research team:         
 
Full Name: Vinh Vo 
Degree:  
Dept. or Unit:  
Professional Email: vinhvo2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 10.22.2021 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       

 
 
Research Team  
 
 
12 of 18 
                             
 
Revised: 4/19/2021 
Date added to research team:     05.20.2022              Date removed from research team:   8/22/2022 
 
 
Full Name: Zoe Faith Levitan 
Degree:  
Dept. or Unit:  
Professional Email: zfl2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 05/13/2022 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:     05.20.2022              Date removed from research team:         
 
 
Full Name: Teresa Warren 
Degree: BS 
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: teresaw3@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 06/02/2022 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   

 
 
Research Team  
 
 
13 of 18 
                             
 
Revised: 4/19/2021 
 This researcher is no longer an active research team member.       
Date added to research team:   06/15/2022                            Date removed from research team:         
 
Full Name: Summer Xia Yu 
Degree: MSW 
Dept. or Unit: Applied 
Health Sciences- SHS 
Professional Email: xiayuyc2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 10/01/2021 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   06/15/2022                            Date removed from research team:         
 
Full Name: Kori Trotter 
Degree: BA 
Dept. or Unit: KCH 
Professional Email: korit@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 4/25/22 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       

 
 
Research Team  
 
 
14 of 18 
                             
 
Revised: 4/19/2021 
Date added to research team:   8/2/22                            Date removed from research team:         
 
Full Name: Eliza Baby  
Degree: MS 
Dept. or Unit: SHS 
Professional Email: ebaby2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/21/2022 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   August 22, 2022     Date removed from research team:         
 
Full Name: Natalia Rzepa 
Degree:  
Dept. or Unit: SHS 
Professional Email: nrzepa2@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): Sept 13, 2021 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   August 22, 2022     Date removed from research team:         
 

 
 
Research Team  
 
 
15 of 18 
                             
 
Revised: 4/19/2021 
 
Full Name: Ahmad Al-Juboory 
Degree:  
Dept. or Unit: KCH 
Professional Email: ahmada@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): August 26, 2022 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   August 29, 2022     Date removed from research team:         
 
Full Name: James Shim 
Degree:  
Dept. or Unit: SHS 
Professional Email: jamesss3@illinois.edu 
Phone:  
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 08/31/22 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   9/9/22                            Date removed from research team:         
 
Full Name: Katie Naveja 
Degree:  
Dept. or Unit: SHS 

 
 
Research Team  
 
 
16 of 18 
                             
 
Revised: 4/19/2021 
Professional Email: knaveja2@illinois.edu 
Phone:  
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:       
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 8/28/22 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   9/9/22                            Date removed from research team:         
 
Full Name: Afnaan Afsar Ali 
Degree:  
Dept. or Unit: 
Department of 
Kinesiology and 
Community Health 
Professional Email: aafsa2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): August 21, 2022. 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, depression index, etc.), please 
specify the procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   10/12/2022                                Date removed from research team:         
 

 
 
Research Team  
 
 
17 of 18 
                             
 
Revised: 4/19/2021 
 
Full Name: Michael Varzino 
Degree:  
Dept. or Unit: 
Department of 
Kinesiology and 
Community Health 
Professional Email: varzino3@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): September 2, 2021 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, depression index, etc.), please 
specify the procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   10/12/2022                                Date removed from research team:         
 
Full Name: Nila Silva de Albuquerque 
Degree: PhD 
Dept. or Unit:  
Professional Email: nila@illinois.edu 
Phone: 217-265-6574 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:  
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify: Post-doctoral research associate 
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): 01/23/2023 
 Additional training, Date of Completion:  
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, etc.), please specify the 
procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       

 
 
Research Team  
 
 
18 of 18 
                             
 
Revised: 4/19/2021 
Date added to research team:   01/28/2023                            Date removed from research team:         
 
 
 
Full Name: Maya Dye 
Degree:  
Dept. or Unit: 
Department of 
Kinesiology and 
Community Health 
Professional Email: mayadye2@illinois.edu 
Phone: 217-300-5445 
Campus Affiliation:  
 University of Illinois at Urbana-Champaign 
 Other, please specify:       
Campus Status: 
 Faculty 
 Academic Professional/Staff  
 Graduate Student 
 Undergraduate Student  
 Visiting Scholar 
 Other, please specify:  
Training: 
 Required CITI Training, Date of Completion (valid within last 3 years): August 21, 2023 
 Additional training, Date of Completion:       
Role on Research Team (check all that apply): 
 Recruiting 
 Consenting 
 Administering study procedures 
 Handling identifiable data 
 Other, please specify:       
If administering biomedical study procedure (e.g., blood draws, scans, depression index, etc.), please 
specify the procedure(s):       
 This researcher should be copied on OPRS and IRB correspondence.   
 This researcher is no longer an active research team member.       
Date added to research team:   8/30/2022                                Date removed from research team:         
 

 
Collaborating 
Investigator 
 
 
1 of 3 
                             
 
Revised: 11/11/2019 
For Engaging in a Collaborating Investigator Agreement for Individuals who are not Affiliated 
with an Institution that has an FWA 
 
COLLABORATOR INFORMATION 
Collaborating Investigator’s Name: Margaret Danilovich  
Collaborating Investigator’s Institution (if applicable):       
CITI Training Completion Date: Sept 13, 2021  
 
PROTOCOL INFORMATION 
The above is a Collaborating Investigator in the following research study being conducted by the University 
of Illinois at Urbana‐Champaign: 
Illinois Principal Investigator: Dr. Wendy Rogers 
Illinois Protocol Number: 22212 
Illinois Title: Video Technology‐based Social Engagement 
Illinois PI Home Unit (DMI Unit Name): Applied Health Sciences 
 
I acknowledge and agree that the University of Illinois at Urbana‐Champaign Principal Investigator will direct 
and supervise my research activities outside the Illinois campus.  
 
I have reviewed the following documents:  (a) The Belmont Report: Ethical Principles and Guidelines for the 
Protection of Human Subjects of Research, available at  http://ohsr.od.nih.gov/guidelines/belmont.html; (b) the 
U.S. Department of Health and Human Services (HHS) regulations for the Protection of Human Subjects at 45 
CFR part 46; and (c)  the terms of Illinois’s FWA; and (d) the Illinois policies and procedures for the protection of 
human subjects, available at https://oprs.research.illinois.edu/. I understand and accept my responsibility to 
comply with the standards and requirements set forth in the above‐identified documents and to protect the 
rights and welfare of human subjects involved in the Research. 
 
I will comply with all applicable international, federal, state, and local laws, regulations and policies that may 
provide additional protection for human subjects participating in the Research.  
 
I will abide by all determinations of the Illinois Institutional Review Board (IRB) and will accept the final 
authority and decisions of the IRB, including but not limited to directives to terminate participation in the 
Research.  
 
I will complete any educational training required by Illinois and the IRB prior to initiating activities related to the 
Research.  
 
I will not enroll subjects in the Research prior to its review and approval by the IRB. 
 

 
Collaborating 
Investigator 
 
 
2 of 3 
                             
 
Revised: 11/11/2019 
I will report promptly to the IRB any proposed changes in the Research.  I will not initiate changes in the 
Research without prior IRB review and approval, except where necessary to eliminate apparent immediate 
hazards to subjects. 
 
When responsible for enrolling subjects, I will obtain, document and maintain records of informed consent for 
each such subject or each subject’s legally authorized representative as required by HHS regulations at 45 CFR 
part 46 and as described in the Research protocol approved by the IRB.  
 
I will report immediately to the IRB any unanticipated problems involving risks to subjects or others in the 
Research.  
 
I acknowledge the IRB’s responsibility for initial and continuing review, recordkeeping, reporting, and 
certification for the Research.  I will cooperate fully with the IRB and will provide all information requested by 
the IRB in a timely fashion. 
 
I acknowledge my responsibility for safeguarding the rights and welfare of each Research subject and that the 
subject’s rights and welfare must take precedence over the goals and requirements of the Research. 
 
Collaborating Individual Investigator’s Signature: ___
 Date: 8.30.21 
 
Printed Name: Margaret Danilovich Degrees: DPT, PhD 
Email Address:  Margaret.danilovich@cje.net 
 
 
Collaborating Investigator’s Institution (if applicable): The Collaborating Individual Investigator employed by 
Institution is authorized to conduct the Research at this Institution under the terms of this Agreement. 
By:  
 
 
 
 
 
 
  Date:   
 
 
 
Authorized Institutional Signatory 
Printed Name:       
Complete Address:       
 
For Illinois: 
Illinois PI Department Head 
Signature: ______
__________________________   Date: __08/31/2021`_______ 
Printed Name:  Kim C. Graber 
Department:     Kinesiology and Community Health 

 
Collaborating 
Investigator 
 
 
3 of 3 
                             
 
Revised: 11/11/2019 
*If signing as a delegate, please include name and title below: 
Name: 
Title:  
 
 
 
Office of the Vice Chancellor for Research 
Susan A. Martinis, Ph.D; Vice Chancellor for Research 
Office of Vice Chancellor for Research 
601 E John Street 
Champaign, IL 61820 
 
 
 
 
 
 
 
 
 
 
 
 
 
OVCR Electronic Signature: 
9/14/2021 

 
Collaborating 
Investigator 
 
 
1 of 3 
                             
 
Revised: 11/11/2019 
For Engaging in a Collaborating Investigator Agreement for Individuals who are not Affiliated 
with an Institution that has an FWA 
 
COLLABORATOR INFORMATION 
Collaborating Investigator’s Name:      Rachel Lessem 
Collaborating Investigator’s Institution (if applicable):      CJE SeniorLife 
CITI Training Completion Date: Sept 13, 2021 
 
PROTOCOL INFORMATION 
The above is a Collaborating Investigator in the following research study being conducted by the University 
of Illinois at Urbana‐Champaign: 
Illinois Principal Investigator: Dr. Wendy Rogers 
Illinois Protocol Number: 22212 
Illinois Title: Video Technology‐based Social Engagement 
Illinois PI Home Unit (DMI Unit Name): Applied Health Sciences 
 
I acknowledge and agree that the University of Illinois at Urbana‐Champaign Principal Investigator will direct 
and supervise my research activities outside the Illinois campus.  
 
I have reviewed the following documents:  (a) The Belmont Report: Ethical Principles and Guidelines for the 
Protection of Human Subjects of Research, available at  http://ohsr.od.nih.gov/guidelines/belmont.html; (b) the 
U.S. Department of Health and Human Services (HHS) regulations for the Protection of Human Subjects at 45 
CFR part 46; and (c)  the terms of Illinois’s FWA; and (d) the Illinois policies and procedures for the protection of 
human subjects, available at https://oprs.research.illinois.edu/. I understand and accept my responsibility to 
comply with the standards and requirements set forth in the above‐identified documents and to protect the 
rights and welfare of human subjects involved in the Research. 
 
I will comply with all applicable international, federal, state, and local laws, regulations and policies that may 
provide additional protection for human subjects participating in the Research.  
 
I will abide by all determinations of the Illinois Institutional Review Board (IRB) and will accept the final 
authority and decisions of the IRB, including but not limited to directives to terminate participation in the 
Research.  
 
I will complete any educational training required by Illinois and the IRB prior to initiating activities related to the 
Research.  
 
I will not enroll subjects in the Research prior to its review and approval by the IRB. 
 

 
Collaborating 
Investigator 
 
 
2 of 3 
                             
 
Revised: 11/11/2019 
I will report promptly to the IRB any proposed changes in the Research.  I will not initiate changes in the 
Research without prior IRB review and approval, except where necessary to eliminate apparent immediate 
hazards to subjects. 
 
When responsible for enrolling subjects, I will obtain, document and maintain records of informed consent for 
each such subject or each subject’s legally authorized representative as required by HHS regulations at 45 CFR 
part 46 and as described in the Research protocol approved by the IRB.  
 
I will report immediately to the IRB any unanticipated problems involving risks to subjects or others in the 
Research.  
 
I acknowledge the IRB’s responsibility for initial and continuing review, recordkeeping, reporting, and 
certification for the Research.  I will cooperate fully with the IRB and will provide all information requested by 
the IRB in a timely fashion. 
 
I acknowledge my responsibility for safeguarding the rights and welfare of each Research subject and that the 
subject’s rights and welfare must take precedence over the goals and requirements of the Research. 
 
Collaborating Individual Investigator’s Signature: _____
_ Date: ___8/30/2021____ 
 
Printed Name: Rachel N. Lessem Degrees: JD, PhD 
Email Address:  Rachel.Lessem@cje.net  
 
Collaborating Investigator’s Institution (if applicable): The Collaborating Individual Investigator employed by 
Institution is authorized to conduct the Research at this Institution under the terms of this Agreement. 
By:  
 
 
 
 
 
 
  Date:  08/31/2021 
 
 
Authorized Institutional Signatory 
Printed Name: Kim C. Graber 
Complete Address: Kinesiology and Community Health 
 
For Illinois: 
Illinois PI Department Head 
Signature: ________________________________   
Date: ___________ 
Printed Name:  
Department:  
*If signing as a delegate, please include name and title below: 
Name: 

 
Collaborating 
Investigator 
 
 
3 of 3 
                             
 
Revised: 11/11/2019 
Title:  
 
 
 
Office of the Vice Chancellor for Research 
Susan A. Martinis, Ph.D; Vice Chancellor for Research 
Office of Vice Chancellor for Research 
601 E John Street 
Champaign, IL 61820 
 
 
 
 
 
 
 
 
 
 
 
 
 
OVCR Electronic Signature:  
9/14/2021 

 
 
Letter of Agreement for Senior Housing Communities 
 
 
I, _______Margaret Danilovich_ (print your name), of  CJE SeniorLife_ (print community name), 
grant permission to researchers from the Aging and Neurocognition Lab and Human Factors 
and Aging Lab at the University of Illinois Urbana-Champaign to recruit participants and/or 
collect data at CJE SeniorLife facilities.  
 
This agreement will be in effect through August 2024. 
 
 
__ _____Margaret Danilovich ____________________________ 
Printed name 
 
____________
____________  
8.4.21 
Signature 
 
 
 
 
 
 
 
Date 
 
 
 
 
Please return this letter to Dr. Raksha Mudar via: 
 
Email: raksha@illinois.edu 
Address:  
901 S Sixth St 
Champaign, IL 61820 
 
Please call Raksha Mudar (217-333-4718) if you have any questions about this form and/or study.