Please answer the following questions provide as much information as possible and elaborate with more information if you answer ‘yes’
(Any personally identifiable information received is kept confidential. All personal information shared will only be shared as necessary for the welfare of the participants. Personal information collected is stored in a secure location and safely destroyed after it is no longer legally required.)
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If you answered “yes” to any of these questions, please explain or elaborate below or alternatively explain in an email.
PLEASE READ AND SIGN THE FOLLOWING STATEMENT
I hereby confirm that I have read and understood the above information and have answered all questions completely and honestly, and have not withheld any information. If I am submitting this form electronically, I agree that my typed name on the signature line below shall be the binding, legal equivalent of my actual signature.
I have read, understood, and have truthfully answered the above questions.
If I have indicated a potential concern, I have provided details.