Participant Inquiry Form

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Dear Parent,

Thank you for your interest in our study. We hope you had a chance to read our brochure on the website: https://my.vanderbilt.edu/inspire/ . This form makes it easy to see if you are eligible for our study. If you are eligible and interested in participating or receiving more information, you may enter in your contact information and we will call you to tell you more about the study and answer questions. This website form is confidential and secure.

If you do not wish to fill out this form, you may always e-mail us directly at inspire@vanderbilt.edu or call us at 615-875-BABY. Thank you again.

Sincerely, INSPIRE STUDY STAFF

WB0. download study brochure.

WB1. Was/will your baby born between June 1 and Dec 31 of this year?

* must provide value

Yes

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WB1A. When is/was the month of your due date?

June

July

August

September

October

November

December

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Thank you for your interest in our study. Currently only babies born in these months are eligible. If anything changes, please contact us or fill out the form again.

WB1B. Are you 18 years or over?

Yes

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Thank you for your interest in our study. Currently we require the baby's parent to be at least 18 years old. If anything changes, please contact us or fill out the form again.

WB2. Is/Was your baby a single birth (not a twin)?

Yes

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Thank you for your interest in our study. Currently only single births (not twins) are eligible. If anything changes, please contact us or fill out the form again.

WB3. Is/was your baby born after you were 37 weeks or more pregnant?

Yes, my baby was born at 37 or more weeks or I am currently 37 weeks or more pregnant

Expect my baby to be born at 37 weeks or more.

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Thank you for your interest in our study. Currently only babies who were born at 37 weeks or more are eligible. If anything changes, please contact us or fill out the form again.

WB4. Was your baby greater than 5 lbs 0 ounces at birth?

Yes

Unsure or baby not born yet

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Thank you for your interest in our study. Currently only babies who weigh at least 5 pounds are eligible. If anything changes, please contact us or fill out the form again.

WB5. Does your baby have one of the following medical conditions?
-cardiopulmonary disease
-condition requiring a ventilator
-bronchopulmonary dysplasia
-cystic fibrosis
-immunodeficiency (including maternal HIV)
-known neurological disease
If you need help answering this question, please check "Don't know" so that research study staff may assist you.

Don't Know

Yes

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Thank you for your interest in our study. Currently only babies without these conditions are eligible. If anything changes, please contact us or fill out the form again.

WB6. Do you have any definite plans to move away from Nashville in the few years.

Yes

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Thank you for your interest in our study. This study requires multiple in-person visits in the first year of life and at age 3. We are currently looking for families that can make this commitment. If anything changes, please contact us or fill out the form again.

WB7. Where is your pediatrician located?

Vanderbilt Doctor's Office Tower

University Pediatrics at 100 Oaks

Rivergate Pediatrics

Goodlettsville Pediatrics

Pediatric Associates of Franklin

Old Harding Pediatrics - Bellevue Office

Have not decided / Don't know

Columbia Pediatrics

Other:

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Thank you for your responses! We would like to tell you about our study. Please enter the your contact information in the following fields so that we may tell you more:

WB8. If "Other" or "Don't Know", to WB7,
Would you be able to come to the Vanderbilt campus for the following visits at scheduled times?

Yes

Yes

Yes

Yes

WB9. Parent First Name

WB10. Parent Last Name

WB11. Street address, city state zip

WB12. Email address:

WB13. Telephone

WB14. How did you first hear about this study?

Maternity Poster/Flyer

Vanderbilt e-mail

Referral Sheet/Brochure from Pediatrician

Research Staff

Other

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WB15. Do you have any comments or questions for us?

Thank you for your information! We will contact you as soon as possible to answer any questions you may have.

Y-M-D H:M

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