| First Name* |
|
| Last Name* |
|
| Child's Name:* |
|
Your Relationship to Child |
| Mother / Father |
|
| Family member |
|
| Friend |
|
| Other |
|
In order to ensure that your child will not be enrolled, we may send you a bracelet that your child must wear at all times so that if you come to the Emergency Department the doctors will know right away that you have chosen not to participate. We need your address to mail the bracelet.
|
| Address* |
|
| Phone* |
|
| Cell Phone |
|
| Email Address* |
|
Reason why you do not want to participate |
I don't want my child to be part of research study |
|
| I think this research has too many risks |
|
| I think one drug works better than the other for my child |
|
I prefer |
| Lorazepam |
|
| Diazepam |
|
| Other |
|
May we contact you for a brief interview to understand how we can make this research study better? |
| Yes |
|
| No |
|
|
|
