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You are about to be asked for personal information, including your contact information, so we can begin to find out if you are eligible to be in this research study. We need to talk to you to finish finding out if you are eligible and if you want to be in the study.

The information you give us on this form is stored on a secure server on the campus of UNC-Chapel Hill and cannot be accessed by anyone outside the UNC research team or the University technology support staff.

If you do not wish to provide your information over the internet, you can call us toll free at 1-866-633-8003.

Please complete the following form. Your information will be submitted via a secure server to our research study staff. Someone from the SEED study will contact you about your eligibility.

Please give us your contact information.

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Please note: Once you submit the Interest Form, your information will be cleared from this page. If you want to print the form, please do so before clicking ‘Submit’.

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Your form was submitted to SEED. You will be contacted by study staff. Thank you for your interest in our research.

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Thank you for your interest. Please call us or email us using the contact information below.

Record Information
Did you receive an information packet about SEED? {{ vm.formdata.recieved_infopacket ? 'Yes' : 'No' }} Source code found on your letter or flyer: {{ vm.formdata.infopacket_sourcecode ? vm.formdata.infopacket_sourcecode : 'None' }}
Contact Information
Contact's Name: {{ vm.formdata.contact_firstname }} {{ vm.formdata.contact_lastname }} Contact's relationship to the child: {{ vm.getContactRelationshipNice() }}
Contact's Address: {{ vm.formdata.contact_addr1 }}
Contact's Address (line 2): {{ vm.formdata.contact_addr2 }}
City: {{ vm.formdata.city }} State: {{ vm.getStateName() }} Zip: {{ vm.formdata.zip }}
Primary phone number: {{ vm.getFormattedPhone() }} Alternate phone number: {{ vm.getFormattedAltPhone() }}
Email address: {{ vm.formdata.email }}
Participant Information
Do you have a child born between Jan 1, 2014 and Dec 31, 2017? {{ vm.formdata.valid_dob ? 'Yes' : 'No' }}
Is the child a boy or a girl? {{ vm.getGenderName() }} What is the child's race? {{ vm.getChildRaceNice() }} Child's date of birth: {{ vm.formdata.child_dob }}
Child's name: {{ vm.formdata.child_firstname }} {{ vm.formdata.child_lastname }}
County Information
Was the child born while his/her mother was living in one of the following NC counties: Alamance, Chatham, Davidson, Durham, Forsyth, Franklin, Guilford, Johnston, Nash, Orange, Person, Randolph, Rockingham, Wake? {{ vm.formdata.born_in_county ? 'Yes' : 'No' }} What NC county does the child live in now? {{ vm.getCountyName() }}
ASD History
Has a doctor or other health care provider ever formally diagnosed the child as having an Autism Spectrum Disorder (ASD), including Autism, Asperger's Syndrome, or Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)? {{ vm.getDiagnosisName() }}
Contact and History
Can we contact the child's biological mother? {{ vm.formdata.child_speaks_english == 1 ? 'Yes' : 'No' }}
Does the child's biological mother speak and read English? {{ vm.formdata.biomother_speaks_english == 1 ? 'Yes' : 'No' }} Does the child speak English? {{ vm.formdata.child_speaks_english == 1 ? 'Yes' : 'No' }}