The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

NocXLpcjKYAi4bFjRV68BSSVmyMF6DHNBNWUTMpmXkgov

Screening Form Speech Fluency Lab

Please complete the survey below.

Based on your response to this survey we will extend the invitation to participate in research studies conducted at the Speech Fluency Lab, Department of Speech, Language, Hearing Sciences, University of Minnesota.

If you are a parent responding on behalf of your child, provide information pertaining to your child in response to the survey questions.

Your information will be secure and saved on a UMN approved site. This information will only be used to provide a description of participant demographics.

Regards,

Speech FluencyLab Personnel

Your name:

Gender

* must provide value

Male

Female

Phone number:

Provide email ID:

* must provide value

Preferred method of communication:

* must provide value

Phone

Date of Birth:

Your age (yrs, mnths):

Today's date:

Handedness:

Right

Left

Both

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Language spoken:

English only

English +

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Specify the other language(s) and years of learning:

On a 7 point scale with 1 being least, rate your proficiency in speaking, reading, and writing the other language(s). Use the form (0,0,0) for each language.

Highest grade completed:

Number of years of post-secondary education?

4 or less

other

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Are you or have you been on prescription medication ?
(e.g., ADD/ADHD, anti-anxiety, depression, muscle relaxers, etc.)

History of developmental delays (speech, language, motor, other) or neurological problems (epilepsy, seizures, concussion, head injury history or neurological disorder)?

Yes

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If yes to the previous question, specify:

Do you have speech, language, hearing, reading or other impairments at this time?

Normal hearing:

Yes

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History of diagnosed speech, language, or reading difficulties?

Speech

Language

Reading

Other

None

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Have you ever consulted a speech-language pathologist?

Yes

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If yes to the previous question, indicate reason and number of years:

Indicate your Interest in participating in research studies at the Speech Fluency Lab, Department of Speech, Language, Hearing Sciences, University of Minnesota?

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.