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Screening Form
Please complete the form below.
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First Name
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Date of Birth
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What city do you live in?
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What state do you live in?
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What category best describes you?
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
Are you 18 or older?
Yes
No
Are you willing to travel to Tampa, FL for in-person study visits?
Yes
No
Maybe
Are you the legal guardian, parent, step-parent, or other primary caregiver of a child with Autism?
Yes
No
How old is your child?
Between 6 yrs and 12 yrs
Less than 6 years old
Older than 12 years old
Does your child have difficulty sleeping?
Yes
No
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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BCFS00966
