2-1-1 Broward
Dial 2-1-1 or 954-537-0211
Child Date of BirthFormat: yyyy-mm-dd Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD
Weeks Premature (put "0" if not premature)
List others assisting with completion of the questionnaire
If your child is between birth and 5 1/2 years and lives in Broward County in Florida she/he can participate in the study. If you decide to participate you will complete two questionnaires about your child's development and you will be asked to supply some background information on your family such as education and ethnic group. The questionnaire and background information will take about 10-30 minutes to complete.
The website is secure and password protected to ensure participant confidentiality. Your email address will only be used to respond to your requests. This database is secure and password protected, accessible only to the specialists. Any identifying information connected to your computer (IP address) will not be recorded at any time.
Submitting the questionnaire indicates that you have read the information provided above. In addition, it indicates that you are willingly agreeing to participate and you allow 2-1-1 Broward care coordinators to share demographic, screening, and referral activities as needed. You may withdraw your consent or discontinue participation at any time without penalty, and you are not waiving any legal claims, rights, or remedies.
Sincerely,
Francisco Isaza
Program Director
954-390-0493 ext. 210
Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.
