613-726-7355 ext 100 613-726-7567

Pre-Screen Questionnaire

Thank you for your interest in this research study. In order to help us determine your child’s eligibility to participate, please complete the following questions and return this form by clicking SUBMIT at the bottom of the form. This information is confidential and will only be shared with the members of the research team at the Center for Pediatric Excellence. If you have any questions, please contact the Clinical Research Coordinator, Suzi, at suzannah.wojcik@cfpe.ca or 613-726-7355 x 101.

After you submit the completed questionnaire, you will be contacted by the study team with next steps.