Questionnaire Consent Form - New Jersey

Questionnaire Consent Form
This research is being conducted by Professor Karin Stromswold and members of the Language Acquisition and
Language Processing Lab in the Department of Psychology & Center for Cognitive Science at Rutgers University.
Purpose: This study investigates how genetic and environmental factors affect children’s linguistic and non-
linguistic development.
Participants: In order to qualify for this study, you must be the parent or guardian of a child who is between 1.5
and 6 years of age. We anticipate that between 1000 and 1500 people will participate in this study.
Procedure. You will complete a questionnaire about your child’s prenatal and neonatal period, attainment of
developmental milestones, special services your child may have received (e.g., occupational therapy, physical
therapy, speech therapy, and special education), and your child's general and language development.
Completion of the questionnaire takes approximately 45 to 60 minutes. Participation in this study is completely
voluntary, and if there are any questions you do not want to answer, you are free to leave them blank. You may be
asked to participate in follow-up studies, in which you will complete additional (shorter) questionnaires and/or your
child will play a series of language games that involve describing what happens in picture books, acting out
sentences, repeating sentences, and/or judging whether sentences are grammatical (e.g., the cat drinks milk) or
ungrammatical (e.g., milk the drinks cat). Completing this questionnaire in no way obligates you to participate in
follow-up studies.
Risks and benefits: There are no known risks or discomforts associated with this study. The results obtained
may eventually aid in the prevention, diagnosis and/or remediation of childhood language and learning disorders.
Compensation: If you return the completed questionnaire, you will receive a $10 gift certificate.
Voluntary participation: Participation in this study is voluntary. Refusal to participate will involve no penalty or
loss of benefits to which you are otherwise entitled. The alternative to participate in this study is to not participate.
What this means is that you can decide to not participate. You are free to withdraw from the study at any time, at no
penalty. Withdrawal from the study will in no way prejudice your future interactions with the personnel
administering or supervising the study, or with Rutgers University.
Confidentiality: All identifying information obtained from this study will be kept strictly confidential, except as
may be required by law. Any information that could be used to identify you or your child will be kept under lock and
key. Data files will not contain potentially identifying information. Upon written request, we will send you a
summary of your child's scores on the general development and language development screening tests.
Consent: I have read and understood the above information, have had any questions answered satisfactorily,
and I willingly consent to participate in this study. I understand that if I should have any questions about my rights
as a research subject, I can contact the Rutgers Office of Research and Sponsored Programs at (732) 932-0150
ext. 2104. I can also contact the Principle Investigator, Dr. Karin Stromswold by email ([email protected]),
or by phone at (732) 445-2448). I have received a copy of this consent form.
Your name (printed): Signature
Your child's name (printed)________ ______________________ Child’s date of birth:
Background information about your child
1. Has your child ever been diagnosed with a language or learning disorder or delay? Yes No
If yes, please describe:
2. Does you child have a parent or sibling with a language or learning disorder or delay? Yes No
If yes, please describe:
3. Which hand does your child prefer to use for writing/drawing? Right Left No preference
4. Are any members of your child's immediate family (parents, siblings) left-handed? Yes No
If yes, please list:
Approved by Rutgers University Institutional Review Board for the Protection of Human Subjects _______
Expires ______________
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