Please review the following information about this short online survey. By submitting this form, you will certify and agree that you have read this information.
1) The purpose of this survey is to help determine if your family is eligible for the BASIC2 research study. It will take about 5 minutes and we will ask you some questions about your child's age, your and your child's height and weight, your and your child's comfort with study procedures, and your contact information.
2) The only risk to you and/or your child in this screening survey is a potential loss of privacy and confidentiality. The information you provide for us in this survey will be kept at Seattle Children's in a secure database. It will only be used for the BASIC2 study by approved staff.
3) There is no benefit to you or your child by completing this survey.
4) This survey is voluntary. You can choose to stop it at any time. If you choose not to complete the survey, it will not affect the care your family receives at Seattle Children's or The University of Washington.
5) To protect your and/or your child's personal health information (PHI), we will follow federal and state privacy laws, including the Health Insurance Portability and Accountability Act (called HIPAA for short).
Only the following persons or groups may use, create, and/or disclose your or your child's PHI for this study:
- The Principal Investigator and the research staff.
- The National Institutes of Health, the people who fund this study.
- Seattle Children's Institutional Review Board members, who help protect human subjects involved in research.
6) We will disclose your and/or your child's PHI when required to do so by law in the case of reporting child or elder abuse, in addition to subpoenas or court orders.
7) If identifiers (like your name, address, and telephone number) are removed from your or your child's PHI, then the remaining information will not be subject to the Privacy Rules. This means that the information may be used or disclosed with other people or organizations, and/or for other purposes.
8) If, at any time, you have questions about this screening survey, your rights as a research participant, any study related injuries, or if you have questions, concerns or complaints about the research you may contact the study coordinator, Maya Rowland email@example.com
or Seattle Children's Institutional Review Board at firstname.lastname@example.org
. If you would like to revoke your authorization, please contact Dr. Brian Saelens at email@example.com
By submitting this form, I certify that I have read and agree to the privacy terms described above as related to this survey.