Thank you for providing your comments about our study. We appreciate your time.
We would like some information about you. This section is completely voluntary and you can provide your comments below.
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| Initials (optional): |
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| Your Gender* |
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| Your Age |
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Your Race: |
| Black or African American |
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| White |
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| Asian |
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| American Indian or Alaskan Native |
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| Native Hawaiian or other Pacific Islander |
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Your Ethnicity: |
| Hispanic or Latino |
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| Not Hispanic or Latino |
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Your Child's Age |
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Do you know a child who has seizures |
| Yes |
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| No |
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If you know a child who has seizures, what is your relationship? |
| Parent/Legal guardian |
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| Friend |
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| Family member |
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| Other (e.g. neighbor, teacher, classmate etc) |
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| If other, please specify: |
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Where did you hear about this study? |
| Community meeting |
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| Hospital advertisement |
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| From someone else |
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| Website |
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| Your doctor |
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| Newspaper |
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| If other, please specify: |
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Your comments about the study |
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May we contact you again to ask your opinions in more detail |
| Yes |
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| No |
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| Contact Phone Number |
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| Contact Email Address* |
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