BCFS001176-Georgetown-Kushlev-AdolescentDevelopment [Screening Form] -

Screening Form

Please complete the screening form below and our team will be in touch. Thank you!

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Parent's First Name

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Parent's Last Name

Parent's Phone Number

Parent's Email Address

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Parent's Date of Birth

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What city do you live in?

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What state do you live in?

Child's First Name

Child's Last Name

Child's Date of Birth

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Child's Gender

Male

Female

Other

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Select all of the following that best describes your child:

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Which of the following best describes your situation?

I have already given a smartphone to my child.

I have a smartphone for my child but have not given it to them yet.

I've decided to give or purchase a smartphone for my child in the next 3 months.

I've decided to give or purchase a smartphone for my child in the next year.

I am not planning to give or purchase a smartphone for my child before the age of 14.

Which of the following best describes your current situation?

My child's phone has an active service plan (e.g., Verizon, AT&T, Sprint, etc).

I plan to connect my child's phone to a service plan in the next 3 months.

I am not planning to connect my child's phone to a service plan before the age of 14.

Can both you and your child participate in the study?

Yes

What is the best method to contact you?

Call

Text

I do not wish to be contacted

Where did you hear about this study?

Online

Study Panel

You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.

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