Research Study Interest Form

Dear Parent or Guardian,

Thank you for your interest in participating in our research study. The aim of this study is to identify blood biomarkers in boys with autism. We are enrolling boys as part of this study as controls. 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 do not have a diagnosis of autism. Compensation of $150 is provided after completing the study.

Please fill out 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.

Please note: if your child has a sibling with autism they cannot participate as a control in this study.

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.)?

3. Name of child: *This question is required.

	First name
	Last name

4. Does your child have a nickname that they prefer to go by?

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

calendar

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

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

9. What is your email address? *This question is required.

10. Best phone number to reach you at: *This question is required.

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

12. Does your child have any medical diagnoses such as diabetes, anxiety, ADD/ADHD, allergies, or asthma? If yes, please list them below: *This question is required.

Please enter an 'other' value for this selection.

13. Does your child have a sibling or half-sibling with autism? *This question is required.

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

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

Please enter an 'other' value for this selection.

16. What is your child's ethnicity: *This question is required.

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

18. 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 - Control Group