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GcktBADkmk7MHRc9gKGZY96xfgq

Teen Brain Training Research Study

We want to help adolescents at risk for future suicide attempts by teaching them to control their own brain activity inside the scanner. They will see their brain activity in real time while they remember happy memories as part of a brain training exercise called neurofeedback. Neurofeedback is a safe and not invasive way to study the mind. Your child could earn up to $485 for participating in this research study.

Eligibility: Adolescents ages 11 to 18 years old who have attempted suicide.

If you and your child are interested, please fill out this survey and we will contact you soon. Thank you!

How did you find out about our study? Check all that apply.

* must provide value

⁯Professional Referral

Advertising ⁯

Hospital ⁯

School ⁯

ER ⁯inpatient unit

Other

Do you have time to answer these questions right now?

* must provide value

Yes

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What is a good phone number for us to call you back?

* must provide value

Alternative phone number?

What is the best time of day to call you?

* must provide value

Morning (9 am - 12 pm)

Afternoon (12 pm - 5 pm)

Evening (5 pm - 8 pm)

Other

What are the best days to call you?

* must provide value

Monday

Tuesday

Wednesday

Thursday

Friday

What time should we call you?

Do you think you and your child might be interested in participating in this study? By answering this question, you will end the survey. We will contact you and set up a time to answer the rest of the questions over the phone.

* must provide value

Yes

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After we determine eligibility, I will be happy to talk with her/him directly is she/he want to ask me any questions. The purpose of these questions is simply to determine whether your child is eligible for our study. Please remember that this is a voluntary screening so you're under no obligation to answer these questions.

Finally, if your child is not at home we encourage you to discuss the study with them and make sure that they want to participate, if your child decides not to participate please call us at 612-888-5669 and we will destroy all the information we collect from you today.

Is your child between the ages of 11 and 17 years of age?

* must provide value

Yes

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(For females only) Is your child pregnant or is there a chance that they could be pregnant?

Yes

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Does your child have current and/or frequent seizures?

* must provide value

Yes

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Has your child ever had residential chemical dependency treatment?

* must provide value

Yes

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Does your child have or has your child received the following diagnosis?

Autism/Autism Spectrum Disorder/Aspergers Syndrome

* must provide value

Yes

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Cognitive Delay/ Mental Retardation

* must provide value

Yes

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Schizophrenia

* must provide value

Yes

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Please name any other mental health diagnoses your child has been given

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Does your child currently have...

Braces

* must provide value

Yes

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Un-Removable Body Piercings

* must provide value

Yes

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Implanted Devices. For example: cardiac pacemakers, implantable insulin pumps, hip implants.

* must provide value

Yes

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Weight over 250 lbs

* must provide value

Yes

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Claustrophobia

* must provide value

Yes

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History of surgery

* must provide value

Yes

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Permanent retainer

* must provide value

Yes

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Tattoos

* must provide value

Yes

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Has your child ever attempted suicide?

* must provide value

Yes

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Within the last year?

* must provide value

Yes

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How many times that you know of has your child attempted suicide?

Has your child recently - i.e. within the last year- said that he/she sometimes thinks of death or dying?

Yes

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In the past, e.g. more than 1 year ago, has your child ever said that he/she thinks of death or dying?

* must provide value

Yes

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It looks like we could schedule you and your child for a first session. Our study staff will call you to schedule a first appointment as soon as possible where we will go into extensive detail about the study. The first visit pays $60 + $15 for parking. The study entails 5 sessions. Your child could earn up to $485. Please fill out the information below and we will contact you soon!

Thank you very much for your interest in our research. Right now your child does not meet recruitment criteria for our study; however, there are many other studies in our department that focus on conditions or situations for which your child may qualify. If you are interested, we can pass on your contact information to them with your permission. If so, please fill in the sections below with yours and your child's information.

Do you give us permission to keep screening info and share it with other studies?

Yes

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Child's name:

* must provide value

DOB:

* must provide value

D-M-Y

Sex:

* must provide value

Race/Ethnicity:

* must provide value

Address:

* must provide value

Child 1 Email:

* must provide value

Child 2 Email:

Child's Cell phone:

Can we leave a message?

Yes

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Please note that we will not enroll your child in the study without parent permission.

Parent/Guardian's name(s):

* must provide value

GUIDELINES AND CONSENT FOR UNSECURED EMAIL CORRESPONDENCE FOR RESEARCH PARTICIPANTS

1. Purpose. By signing this form, you are agreeing that we may communicate with you through unsecured emails. This form identifies some of the risks of unsecured emails, provides guidelines for use, and documents your consent.

2. Unsecured Email Risks. Unsecured emails can be inadvertently misdirected by the sender or intentionally intercepted by third parties. The University of Minnesota cannot and does not guarantee the confidentiality of unsecured emails, nor is it responsible for unsecured emails that are lost due to technical failure during composition, transmission and/or storage.

3. Privacy and Confidentiality. Unsecured emails are not a secure method of communication. The content of an unsecured email may be viewed by any person who has access to your email account. Unsecured emails that you send us may be viewed by other staff depending on the nature and timing of your unsecured emails, and may be monitored by the University to ensure appropriate use. Unsecured emails may be viewed by your employer if you are using a work email account. Different University staff may view and process unsecured emails depending on the time of day you send them, or when your typical point of contact is not available. Communication by phone, postal mail, and secure email are considered secure. You should consider using these forms of communication.

4. Content. Unsecured emails should be used only for non-sensitive and non-urgent issues. You should limit the amount of health information in your unsecured emails to us to the minimum necessary.

5. Ending Unsecured Email Communication. This authorization does not have an expiration date. We may discontinue using unsecured emails as a means of communication with you by notifying you by unsecured email or letter. You may discontinue using unsecured emails as a means of communication by notifying us by e-mail to privacy@umn.edu or by letter to:
Health Information Privacy & Compliance Office
410 ChRC (MMC 501)
426 Church Street SE
Minneapolis, MN 55455.

6. Authorizing Signature. I am the research participant or personal representative authorized to act on behalf of the participant. I have read and understand the information regarding guidelines for unsecured email correspondence and had any questions answered to my satisfaction. By signing and providing my contact information below, I agree to communicate by unsecured emails using the email address below:

Parent 1 Email:

* must provide value

Parent 2 Email:

Signature of Research Participant or Research Participant's Personal Representative:

Add signature

TELEPHONE INFORMATION

Home phone (Landline):

Can we leave a message?

Yes

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Work phone (Landline):

Can we leave a message?

Yes

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Parent Cell phone:

Can we leave a message?

Yes

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There is a small risk of exposing your identity whenever unencrypted communication is used. Can we text you, email you and your adolescent/teen child using your provided email and cellphone?

* must provide value

Yes

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Thank you for answering the survey. We will review your answers and contact you to schedule an appointment if we think you may be a good fit or to ask any additional questions about the answers you provided.

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.