Informed Consent - Child version

CONSENT FOR PARTICIPATION IN RESEARCH - CHILD

I declare to be (type the child's name) ___________________________________ Parent/Legal Guardian.
I give permission to Dr. Faedda and his associates to use the following data regarding my
child for research purposes:
• Neuropsychological and/or Psychological testing reports;
• Questionnaires included in the Active Surveys;
• DailyLog™ records;
• Activity Monitoring data;
• Information obtained during clinical interviews/treatment sessions;
• Data from the school or other professionals involved in the child's care.

1. I am aware that all records and information are confidential and will be treated anonymously.
2. The data collected belongs to the principal investigator, Dr. Gianni Faedda.
3. My participation is voluntary, and can be revoked at any time by simply notifying the doctor.
4. My child's treatment will not be affected by a decision to participate or not to participate in this research.
5. There are no risks involved in my child's participation in this project, other than possible loss of confidential information.
6. The benefits to you include an in depth evaluation of certain aspects of your child's illness with potential benefits to his/her treatment.

Thank you for your participation,

Gianni Faedda

____________________________________________________________
Sign, print name and date

____________________________________________________________
Gianni L. Faedda, M.D.

____________
Date

This document has to be provided in original form. Please mail your signed and dated copy to the Center.
You can request a copy after it has been filed in our system. Thank you for your cooperation.