Research Study Interest Form

Dear Parent or Guardian,

Thank you for your interest in our research study. The aim of this study is to identify blood biomarkers in boys with Autism Spectrum Disorder (ASD) to help with earlier diagnosis and to develop potential therapeutic interventions. Your child can participate in this study if they live in United States, they are ages 18 months to 8 years of age, and they have been diagnosed with autism. Compensation of $150 is provided after completing the study.

Please complete the Research Study Interest Form below for each child who is interested in participating in the study. We will review the information you provide and follow-up shortly.

Thank you for your time.

Laura Hewitson, Principal Investigator
The Johnson Center for Child Health and Development
Austin, TX
lhewitson@johnson-center.org

1. Name of parent or legal guardian completing this form: *This question is required.

	First name
	Last name

2. Relationship to child (mom, dad, step-mom, step-dad etc)? *This question is required.

3. What is your child's name? *This question is required.

	First name
	Last name

4. Does your child have a nickname we should use?

5. Child's date of birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

8. Address (please fill this out carefully as this is the address we will use for shipping the lab kit): *This question is required.

	(Street)
	(City)
	(State)
	(Zip)

9. Best phone number to be reached at: *This question is required.

10. Email address *This question is required. This question requires a valid email address.

11. What are your preferred days and times for us to contact you? *This question is required.

12. Which of the following diagnoses applies to your child? Please select the one that most closely applies: *This question is required.

Please enter an 'other' value for this selection.

13. Who made this diagnosis? *This question is required.

Please enter an 'other' value for this selection.

14. Will you be able to provide a copy of your child's diagnosis? *This question is required.

16. Does your child have any genetic, metabolic, or neurologic diagnoses? *This question is required.

17. Is your child comfortable getting a blood draw at a local center (e.g. Any Lab Test Now)? We can also work with a mobile phlebotomist (nurse) to come to your home, which may be easier for some children. *This question is required.

18. What is your child's race? Check all that apply: *This question is required.

19. What is your child's ethnicity? *This question is required.

20. Feel Free to make any additional comments here, and/or write down any questions you may have.

21. How did you hear about this study? If someone referred you, please add their name below so we can thank them.

Research Study Interest Form - Autism Group