Self Administered Forms (Mother)

Attachment 8.p.

Study to Explore Early Development

CONSENT SIGNATURE FOR FORMS

Thank you for taking part in the Study to Explore Early Development (SEED). The purpose of this research study is to find out more about possible causes for autism and other developmental disabilities. Results may lead to better services and treatments for children with autism and related disabilities.

Some of the forms in this packet will ask about your family medical history. Others will ask about your child’s development. It will take about <select time depending on workflow group: 1, 1 ½, 2> hours to complete all the forms. You agree to be in this part of the study if you sign this form and complete and return the forms in the packet.

Some of the questions may make you feel uneasy. You can skip any question you do not want to answer. All information you give will be put into a computer database. Only project staff will have access to the database.

Because sensitive information is collected in this study, <site> received a ‘Certificate of Confidentiality.’ This means that any information that <site> has that identifies you or your child will be used only for this project. It cannot be given to anyone else unless you give your written consent.

Your participation in this study is voluntary. You can drop out of the study at any time. There is no penalty if you do not want to be in the study.

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Signature Date

* If you have questions about the study you can call <PI or project coordinator> at <phone number>. If you have questions about your rights as a research participant you can call <name> at <number>.

Version 9-2015 1