Exercise and Video Game Study Screening Consent Form
You have been invited to take part in a research study about the effects of long-term video games and exercise on learning, memory, cognition and mood. The Principal Investigator for this study is Dr. Julia C. Basso at the Center for Neural Science, New York University. Her faculty sponsor is Dr. Wendy A. Suzuki at the Center for Neural Science, New York University.

Before you can enter the study, you will first need to complete a screening questionnaire to assess whether you fit the study's eligibility criteria. The study involves the use of an Electroencephalography (EEG) cap while subjects perform cognitive tests on the computer. EEG is a safe, non-invasive method to record electrical activity of the brain along the scalp. For this reason, as part of this screening questionnaire, you will be asked a variety of questions regarding your medical and mental health. All of your information will be kept confidential with a unique Subject ID number, accessible only to the Principal Investigator and affiliated research staff for the study purposes. There are no known risks associated with your participation in this questionnaire beyond those of everyday life. You have the right to skip any questions you prefer not to answer. Completion of this questionnaire will take approximately 10 minutes. If you do not wish to submit your answers, simply close out of the form and your answers will not be recorded.

You will be notified regarding your eligibility status shortly after you submit this questionnaire. All data from this questionnaire will be kept on file electronically for the duration of the study and destroyed thereafter. Furthermore, if you are eligible and agree to participate in the study, you will be asked to verify your identity through a valid form of identification before enrollment begins. In addition, there may be additional screening tests conducted in-person or on the phone depending on your answers to the questionnaire.

If you agree to be in this study, you will be randomly assigned to either a video game control or an aerobic exercise group. Participation in this study is completely voluntary. You may refuse to participate or withdraw at any point. Reimbursement for participation in the study will be prorated accordingly. Additionally, the Principal Investigator has the right to remove subjects from the study at any point if it is determined that certain eligibility criteria were not met or responses were inaccurate.

If there is anything about the study that is unclear, if you have any questions or wish to report a research-related problem, you may contact Dr. Basso at jb4590@nyu.edu or (212) 998-3969. For questions about your rights as a research participant, you may contact the University Committee on Activities Involving Human Subjects, New York University at 665 Broadway, Suite 804, New York, New York, 10012 - ask.humansubjects@nyu.edu or (212) 998-4808.

You may print out a copy of this consent document to keep for your records.

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