Consent Form

Dear Parents,

You are invited to participate in a research study that will investigate the use of an online developmental questionnaire to help families check their child's development and, if needed, access services in their community

If your child is between birth and 5 1/2 years she/he can participate in the study. If you decide to participate you will complete one or two questionnaires about your child's development and you will be asked to supply some background information on your family such as education and ethnic group. The questionnaire and background information will take about 10-30 minutes to complete.

All your responses will remain anonymous unless you instruct our team to get in touch with you regarding questionnaire responses. Your name will not appear anywhere on the questionnaire (unless you indicate it on hard copy version). Websites are secure and password protected to ensure participant confidentiality. Upon submission, answers are sent directly to the researcher with random identification number that is created when you submit the consent form. The identification number provides anonymity of data stored on a separate, secure database. Your email address will only be used to respond to your requests. This database is secure and password protected, accessible only to the researchers on this project. Any identifying information connected to your computer (IP address) will not be recorded at any time. In addition, all data will be analyzed according to groups rather than by individual case.

There are benefits involved for participants and for humanity in general. An accurate screening tool for development may improve the quality of life for some children by providing referral information for further assessment and early intervention services in a timely manner. Participants will be provided a contact email and phone number to discuss any concerns related to their child's development.

If you have any questions regarding the research, contact Jane Squires at (541) 346.2634. You may also reach us at the Early Intervention Program, University of Oregon, 5253 University of Oregon, Eugene, OR 97403-5253. If you have any questions regarding your rights as a research subject, please contact Research Compliance Services at 541.346.2510. Thank you for your help.

Submitting this form indicates that you have read and understand the information provided above, that you willingly agree to participate, that you may withdraw your consent at any time and discontinue participation at any time without penalty, and that you are not waiving any legal claims, rights or remedies.

You may save this consent form and print for your records here.

Sincerely,

Jane Squires, Ph.D.
Ages and Stages Questionnaire Project
541.346.2634

*The principal investigator, Dr. Squires, is one of the authors of the ASQ, and the assessment is commercially available and published through Brookes Publishing Company, Inc.

: