ICCD Research Study Form

Research Study Form

* Required

1. IntegReview has approved the information in this consent form and has given approval for the investigator to do the study. This does not mean IntegReview has approved your being in the study. You must consider the information in this consent form for yourself and decide if you want to be in this study.

   STATEMENT OF VOLUNTARY CONSENT
   I have read this form and decided that I will participate in the project described above. The general purposes and particulars of the study, as well as possible hazards and inconveniences, have been explained to my satisfaction, and I agree to my participation. *
   Yes, I give my consent to participate in this survey.

2. We may be interested in contacting participants for follow-up data in the future (i.e., to have you complete this measure again at a later date). If you agree to the research team inviting you to participate in future studies, please write your preferred email address or phone number below:
   

3. If you are interested in entering the raffle for a $50 Amazon gift card, please write your email address below:
   

4. Please enter today's date. *
   

5. Please enter your child's birthdate. *
   

6. What is your child's gender? *
   

7. What is your child's race/ethnicity? *
   

8. Child's diagnosis (if any)? *
   

9. Is this child your 1st, 2nd, 3rd, etc.? *
   

10. Did your child have colic? *
    YesNo

11. If yes, was there a medical determination for colic?
    YesNo

12. Did your child participate in Early Intervention?
    YesNo

13. If yes, for what services?
    

14. Who is completing this form? *
    Biological ParentAdoptive ParentFoster ParentOther

15. INSTRUCTIONS: Here are some things parents may say about their child. Read each item carefully, then mark how well it describes your child or how frequently it happens. *

    	Not True at All (Almost Never)	Just a Little True (Occasionally)	Pretty Much True (Often)	Very Much True (Almost Always)
    1. My child has temper tantrums that are longer than expected for his/her age.	neveroccasionallyoftenalways
    2. My child has a consistent sleep schedule.	neveroccasionallyoftenalways
    3. My child throws, breaks, or destroys things during a temper tantrum.	neveroccasionallyoftenalways
    4. My child dislikes the feel of certain things (e.g., clothing, water, “messy” things).	neveroccasionallyoftenalways
    5. My child has a temper tantrum or loses their temper “out of the blue”.	neveroccasionallyoftenalways
    6. My child is easy to please with meals or snacks.	neveroccasionallyoftenalways
    7. My child is tense, fearful, or anxious.	neveroccasionallyoftenalways
    8. My child wakes up very early in the morning (i.e., earlier than necessary or desired).	neveroccasionallyoftenalways
    9. My child is explosive or aggressive.	neveroccasionallyoftenalways
    10. My child tends to rock/bounce while sitting.	neveroccasionallyoftenalways
    11. My child seems very sensitive to light.	neveroccasionallyoftenalways
    12. My child is quiet and calm.	neveroccasionallyoftenalways
    13. My child has trouble falling asleep at night.	neveroccasionallyoftenalways
    14. My child regularly leaves food on his/her plate at the end of a meal.	neveroccasionallyoftenalways				15. My child has eating problems, such as stuffing food, gagging, or vomiting.	neveroccasionallyoftenalways				16. My child wakes up frequently during the night.	neveroccasionallyoftenalways				17. My child is hypersensitive to smells.	neveroccasionallyoftenalways				18. My child has more frequent temper tantrums than expected.	neveroccasionallyoftenalways				19. My child has difficulty calming down when angry.	neveroccasionallyoftenalways				20. My child takes longer than 30 minutes to complete a meal.	neveroccasionallyoftenalways

16. INSTRUCTIONS: Here are some things parents may say about their child. Read each item carefully, then mark how well it describes your child or how frequently it happens. *

    	Not True at All (Almost Never)	Just a Little True (Occasionally)	Pretty Much True (Often)	Very Much True (Almost Always)
    1. My child will smell toys, clothes, or food more than usual.	neveroccasionallyoftenalways
    2. My child frequently bumps into or rubs against hard surfaces, even though it hurts.	neveroccasionallyoftenalways
    3. My child is hypersensitive to sounds.	neveroccasionallyoftenalways
    4. My child becomes frustrated easily.	neveroccasionallyoftenalways
    5. My child has a strong need to touch people and objects.	neveroccasionallyoftenalways
    6. My child chews or eats nonfood items.	neveroccasionallyoftenalways

17. Have you started or completed potty training? *
    YesNo

18. IF YES, PLEASE ALSO ANSWER THE FOLLOWING:

    	Not True at All (Almost Never)	Just a Little True (Occasionally)	Pretty Much True (Often)	Very Much True (Almost Always)
    1. My child has/had difficulty being daytime toilet trained (i.e., later than expected).	neveroccasionallyoftenalways
    1. My child has toileting accidents during the day.	neveroccasionallyoftenalways
    3. My child has/had difficulty being nighttime toilet trained (i.e., later than expected).	neveroccasionallyoftenalways
    4. My child stays dry during the night.	neveroccasionallyoftenalways