ࡱ > 0 2 / bjbjVV 4 < < | | % = ! 㣞 j 0 % i# N L i# i# . % i# | : Thank you for your participation in Genetic Studies of Human Developmental Disorders through the 91 College of Wisconsin and Childrens Research Institute.
We would like to invite you to provide feedback regarding your experience as a part of this study. Please complete this survey and return in the enclosed postage paid envelope.
Was a genetic cause of your/your childs eye disorder identified as part of this study?
____Yes ____No
When did you get the results?________________________________
If yes, what was the impact of these results for you/your family?
____ Positive ____Negative
How do you plan to use these test results? (Choose all that apply)
____ Provided/confirmed diagnosis in child
____ Gave information about other problems to watch for in child
____ Will use for family planning/prenatal testing
____ Other (please describe):____________________________
______________________________________________
What was your reaction to these results?
_____________________________________________________
_____________________________________________________
Please share any other comments or concerns regarding this study:
_____________________________________________________
_____________________________________________________
_____________________________________________________
With your permission, we may use these comments in promotional materials such as the laboratory website, study reports/publications, newsletters, and donor solicitation materials. Please choose from the options below (more than one option may be checked):
_____ You have my permission to publish a quote from the comments above identified as mother/father of child with (diagnosis) or patient with (diagnosis).
_____ You have my permission to publish a quote from the comments above including my name and the condition in my family (ie: Jane Doe, mother of child with glaucoma).
_____ You have my permission to publish a quote from the comments above along with a picture of my son/daughter.
_____ Please do not publish my comments.
Please provide your contact information in case we need to reach you regarding a publication of your comments:
Name: _________________________ Address:_____________________________
Phone: _________________________ ______________________________
Todays date: ___________________
Thank you for your time!
If you have any other questions, concerns, or comments about this study, please contact Linda Reis, MS, CGC, Program Coordinator, at 414-955-7645.
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