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Required format:

/^35150-\d+$/

/^[A-Z]+\d+$/

/^[-A-Z0-9]+$/

/^AMEL(?:[A-Z]?)\d{2,}$/

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^[A-Za-z]{4}\-\S{4}$/i

/^\d+-\d+$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(0[1-9]|1[012])([-\/.])?(\d{4})$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(\d{4})([-\/.])?(0[1-9]|1[012])$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^R0[2-6]-\d{4}$/

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/^[-+]?\b\d+\b$/

/^(?:\d{1,3}\.){3}\d{1,3}$/

/^\d*\.?\d*$|^[nN]\.?[dD]\.?$/

/^[a-z]+$/i

/^([0-9A-F]{2}[:-]){5}([0-9A-F]{2})$/i

/^(([0-9a-f]{2}[:-]){5,}([0-9a-f]{2})(,\s*)?)+$/i

/^(?:MC?|TEST)\d{2}-\d$/

/^\d{10}$/

/^\d{7,8}$/

/^[a-z0-9-_]+$/i

/^\d\d_T\d\d_[A-Z\-]{3}$/

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

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/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\w{32}$/

/^\d{3}-\d\d-\d{4}$/

/^([a-zA-Z][a-zA-Z0-9]{1,7})$/

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/^([0-9]|[0-1][0-9]|[2][0-3]):?([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^TPCD?\d{2,}/

/^TPFD?\d{2,}/

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QihqnWhPZ2H8NQc7m4sQhVv4kdZFYBcM22wXYCXIGEffYDqLNNeRtyjogZMHKNEguFbncymSJIQDVHAc33CYdNGz

E-Screening

The purpose of this screening questionnaire is to determine if your child meets the criteria for taking part in our cognitive training research study.

The questionnaire will take approximately 30 minutes and include personal questions regarding your child's current medical status as well as certain previous medical and developmental history that may impact the study. Information that you provide will be kept as confidential as possible as required by law. If you or your child do not want to answer these questions, you may choose not to participate in this study. You may withdraw from this study at any time, even if you complete this screening. If you decide to withdraw from this research study, please call Dr. Hosseini at (650)-723-5798. There are no anticipated consequences to withdrawal from the research study. The risk for completing this questionnaire is that you may feel uncomfortable answering personal questions. If your child qualifies to take part in the study and are interested in taking part in it or in future research studies, then I will record your name and information. If you are not interested in the study, then I will destroy the personal information you give me. The benefit to you of completing this questionnaire is that you will find out whether your child can participate in our study. The benefit to you of being in our database is that you will hear about studies in the future that you may be interested. We cannot and do not guarantee or promise that you will receive any benefit from this study. You will not be paid for completing the questionnaire or being in the database. If you do not qualify for this study, or if you choose to withdraw your participation from this screening, your name and information will be destroyed unless you give us permission to use it for future studies. Your participation in the study is voluntary and you do not need to fill out this questionnaire if you are not willing to participate in this study.

In the future, if you have any questions about this screening procedure, please call Hannah Fingerhut at (650)-724-2939. If you have any questions about your rights as a study participant, please call the Human Subjects Office, (650)-723-5244.

Please print a copy of this page for your records.

If you agree to participate in this research, please complete the following questionnaire.

Your first name:

* must provide value

Your last name:

* must provide value

Your child's first name:

* must provide value

Your child's last name:

* must provide value

Your phone number:

* must provide value

Your email address:

* must provide value

Your child's date of birth (m-d-y):

* must provide value

M-D-Y

Your child's gender:

* must provide value

Female

Male

Other

E-Screening

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