Emerson College - Research

Are you signing up an adult, or a child?

Adult Child

Please enter the following information for the individual interested in participating in research:

Please enter the following information for your child:

Fields marked with a red asterisk * are required.

First name: * Last name: * Date of birth: * (MM/DD/YYYY) Sex: *

Parent(s) names: *

Place of birth (city & country): Highest level of education completed: Occupation: Ethnicity: *

Please select all that apply

Native language: If not a native English speaker, when did you learn English?

Does the person interested in participating in research have a communication disorder or difficulty? *

Please check all that apply:

Aphasia Apraxia Dementia Difficulties with articulation Difficulties with memory Difficulties with understanding language Difficulties with word finding

When were the symptoms first noticed? (Month and year.) When was the communication problem first diagnosed? (Month and year.)

Has the participant been diagnosed with a hearing deficit?

Does your child have any diagnosed developmental disorders or disabilities? *

Please check all that apply:

Autism spectrum disorder (including autism, ASD, Asperger's, and PDD-NOS) Genetic disorder (please specify below) Intellectual disability Language disorder or impairment Other (please specify below)

Has your child been diagnosed with hearing loss?

Please list any siblings, if you would like them to also participate in studies.

First Name: Last Name: Birth Date: (MM/DD/YYYY) Sex:

Does this sibling have any diagnosed developmental disorders or disabilities?

Please check all that apply:

Autism spectrum disorder (including autism, ASD, Asperger's, and PDD-NOS) Genetic disorder (please specify below) Intellectual disability Language disorder or impairment Other (please specify below)

Has this sibling been diagnosed with hearing loss?

Best contact information:

*Phone number and email is required.

Name of Contact: Relationship to participant:

Phone number: * (123-456-7890) Alternate phone number: (123-456-7890) Email: * Street address: City: State: Zip:

All information entered into this form is securely stored for later use in selecting research study candidates. This information will never be used for any other purposes. If you have any questions, please contact rhiannon_luyster@emerson.edu.

Department of Communication Sciences & Disorders

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