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Survey Consent Agreement

Participation/Procedure
I hereby consent to participate in a research survey conducted by the American Partnership for Eosinophilic Disorders (APFED). Participation is open to all members of APFED. I understand that I will complete the survey and that my participation is completely voluntary. I understand that my participation in this survey may contribute to a greater understanding of the factors that influence eosinophilic disorders from childhood throughout adulthood.

Usage/Confidentiality
I understand that the results of this survey may be published or reported to government agencies, funding agencies, or scientific groups, but that my name will not be associated in any way with any published results. In order to secure your data, we will maintain your email address and/or username to identify you and stop people from registering as you for the duration of the survey. When the survey has completed, all such identifying information will be destroyed, and none of your responses will be in any way traceable back to you.

Consent
I acknowledge that I understand my rights as a survey participant as outlined above. I acknowledge that my participation is fully voluntary. By clicking the consent box below, I freely consent to act as a participant in this survey.

0-2 Years
3-5 Years
6-11 Years
12-18 Years
Over 19 Years

Yes - formula only, no foods
No - formula + 1-10 foods
No - formula +>11 foods

By mouth (drinks)
By nasogastric (NG) tube
By gastrostomy tube (GT)
By gastrojejunostomy tube (G-J)

Neocate
Elecare
Other: please specify

Yes - full coverage
Yes - partial coverage, please specify amount paid out of pocket per month:
                                                                                   
Supplemental state assistance coverage for DME
No coverage at all, pay out of pocket

Extremely Important
Very Important
Not very important
Not important at all