MIT Biomechatronics Research Group: Upper Limb Prosthesis Study Interest Form

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Your responses in this form will be used to determine candidacy for an ongoing upper limb prosthesis research study.

Please direct any questions to both of the following researchers: Michael Fernandez (mfernan[at]media.mit.edu) and Maria Ramos Gonzalez, PhD (mariarg[at]media.mit.edu)

Email *

First Name *

Last Name *

Phone Number *

Age *

Upper limb amputation location (select all that apply) *

Left arm above elbow

Left arm below elbow

Left arm partial hand

Right arm above elbow

Right arm below elbow

Right arm partial hand

Other:

Required

Cause of amputation(s) (select all that apply)

Trauma

Congenital

Diabetes

Other:

Years since amputation(s). If multiple amputation sites on the upper limbs, please provide the date of each site. *

Did you receive targeted muscle reinnervation (TMR) or regenerative peripheral nerve interfaces (rPNIs) in any form during your amputation procedure? If so, please provide details on the nature of your neural interfaces.

Do you have any metal implants or contraindications that would make you ineligible for fMRI brain scan (if unknown, please answer N/A)

Do you own a myoelectric prosthesis for your upper limb amputation(s)? *

How often do you use your myoelectric prosthesis? *

Every day (7 days a week)

Often (4 - 6 days a week)

Sometimes (1 - 3 days a week)

Rarely

Never

I do not own a myoelectric prosthesis for my upper limb amputation

What device(s) do you have?

Can you commit to up to 4 contiguous full days of testing at the MIT Media Lab? ( coordination of travel, hotel lodging, food will be provided)
*

We are located at 75 Amherst St., Cambridge, MA 02142. Our dates are flexible; we will work with you to find times that are appropriate.

Do you have anything else you would like to share?

A copy of your responses will be emailed to the address you provided.

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