If you are interested in having your child screened as part of our research, please read and agree to the following consent.
The Florida State University College of Medicine FIRST WORDS® Project
Project Title: Smart Early Screening for Autism and Communication Disorders in Primary Care Sponsor: National Institutes of Health Principal Investigator: Amy M. Wetherby, Ph.D., Florida State University
Phone: 850-644-4367 Email: firstname.lastname@example.org
Parent Permission Form
About this Study:
You are being invited to take part in a research study. This study is conducted by the FIRST WORDS Project at the Florida State University College of Medicine.
The purpose of the study is to help find communication delays and autism earlier. The Smart ESAC is used as the first step in screening for autism and communication delays. For some children the delays can be very mild, and for others they can be more noticeable. We want to be able to find delays early so that we can help parents when their children are still very young.
You are eligible for this study if your child is between 9 and 18 months of age and a parent or legal guardian is able to speak English in order to complete the screening tool and discuss the results. You will need to provide your first and last name, an email or cell phone number that can receive text messages, your child’s first and last name, gender, and birthdate.
We are asking your permission to invite you to complete the Smart ESAC to screen your child and use the information you provided for our research. We will share the screening results with you in the FIRST WORDS Project Parent Portal. We may contact you to schedule a phone call to discuss the screening results and invite you to bring your child for an evaluation. You can contact email@example.com if you have any questions. Your participation will not cost you anything.
You can decide when we contact you if you want to hear more about the study and if you want to participate in an evaluation. We will not use your name or contact information for any other reason. The names of all children and families participating in this study will be kept strictly private to the extent allowed by law. Your name or contact information will not be used when reporting research findings.
The information you provide may help your child access early intervention services and help us identify other children with autism and communication problems earlier. Being contacted by the FIRST WORDS Project to learn about the study is entirely your choice. You can always change your mind later. If you decide not to participate in this study, you will not lose any medical benefits. Your doctor will continue to treat you.
By signing this permission form, you are agreeing to participate in this study by letting us use the information you provided and contact you. If you have any questions about this study, please don’t hesitate to call the FIRST WORDS Project at (850) 488-5780. If you have any questions about your participation in this research, you can also contact the Chair of the FSU Human Subjects Committee, Institutional Review Board at (850) 644-8633 or firstname.lastname@example.org.
2312 Killearn Center Blvd., Building A Tallahassee, Florida 32309 Telephone 850.488.5780 Fax 850.644.3644