The Scott Center Research Recruiting Survey
RequiredRequired Question(s)
Please complete the form below to volunteer to participate in a research study! 
 
Required 1.
PARENT or GUARDIAN's contact information

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.
Child's First Name
 

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3.
Child's Last Name
 

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Required 4.

Child's date of birth (MM/DD/YYY) please include month, day, and year

 

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Required 5.

Gender of the child?

Male
Female
Required 6.
What is the child's diagnosis? Check all that apply.
No Diagnosis
Developing Typically
Developmental disability
Autism
Other  
Required 7.
What is the child's communication ability (check the one option that applies best)
Communicates in complete sentences and able to conduct a conversation
Verbally limited, uses one and two word phrases
Primarily sign language with little or no verbal language
Picture communication and pointing
Other  
Required 8.

What concerns do you have regarding the child's behavior: (check boxes of all that apply)

Feeding difficulty and food selectivity
Toilet training
Language and communication
Problem behavior, such as tantrums, self injury, school disruption, etc.
Social skills
Other  
9.
If there is a specific research study that you are interested in, please name it here: 
 

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Required 10.

[HIPPAA STATEMENT]  

Please read and agree to the following statement: 

  

*"I understand and agree that in order to determine if I or the person described in this form, for whom I am the parent or legal guardian, can be deemed candidates for a research study, the information in this form will be shared  with people conducting the research study. If we are deemed qualified candidates, I also understand that I may be required to complete additional informed consent/privacy authorizations to participate in the study."


Yes, I understand and agree.
No. (If selected, please do not submit this form)
Required 11.

[HIPAA STATMENT CONTINUED]


 

*Please type your full name in the box below to indicate your agreement and understanding that the information in this form will be shared with the Scott Center and Florida Tech research staff.




 

50 characters left.