1. About This Study:

Dear Participant,

Thank you for your considered participation. My name is Mischelle Miller-Raftery and I am a doctorial student in psychology at California Southern University. I am conducting a study on potential prenatal environmental triggers of autism. The goal of this study is to better understand the potential effects on a fetus when exposed to certain environmental triggers. This study is being conducted under the supervision of Barbara Lackey, PhD., Professor of Psychology, Southern California University.

This survey is for mothers of children who have been diagnosed with autistic spectrum disorder (Asperger’s Syndrome, autism, and pervasive developmental disorder-not otherwise specified). This survey asks general questions about your environment and lifestyle choices during pregnancy. You will be asked to fill in each question for the time period during your pregnancy with the child who was diagnosed with autism. The premise of this study is to look for trends between environmental exposures and autism. Specifically, this study explores multiple exposure combinations which might have occurred during your pregnancy. The goal of this study is to explore the possible environmental influences on autism. This study could potentially help professionals and mothers make informed decisions with regards to environmental exposures and life style choices during pregnancy in an effort to reduce the recurrence of autism.

To qualify for the study, you must meet the following criteria.
• Your child must have been diagnosed with autism spectrum disorder including Asperger’s Syndrone, autism, and pervasive developmental disorder- not otherwise specified.
• Your baby must have been considered full-term (born after 37 weeks).
• Your child must have no other developmental diagnosis.
• Controlled group – Have a child over the age of three with no known illness diagnosis.

Your participation in this study should take about 25 minutes to fill out the questionnaire. If you need more information about the study, or have a particular question, please email Mischelle Miller-Raftery at mm@mischellemiller.com or call (310) 994-9278. If you would prefer to complete this study non-electronically, please send me an email with your name and address and a survey will be mailed to you. We greatly appreciate your participation in this study.

Sincerely,
Mischelle Miller-Raftery
mm@mischellemiller.com
(310) 994-9278

STATEMENT OF INFORMED CONSENT
Environmental Exposures and Autism

I have been informed that this research project is being conducted by Mischelle Miller-Raftery as part of the requirements for the doctorate degree in Psychology at the Graduate School of Psychology, Southern California University. I understand that this study is being conducted under the supervision of Barbara Lackey, PhD., Professor of Psychology, Southern California University.

I understand that my participation is voluntary. I understand that I may refuse to participate or withdrawal from this study at any time. I also have the right to decline to answer any question that I do not want to answer. I understand that I have been asked to participate in this study to provide information about various aspects of my pregnancy while I was pregnant with my child who was later diagnosed with autism.

I agree to answer a series of questions about the time I was pregnant with my child that was later diagnosed with Autism. I understand the questions will focus on environmental factors and life style choices during my pregnancy including but not limited to demographic information like age, weight and location during pregnancy; a consumption profile including certain foods consumed as well as alcohol or other drugs; questions relating to indoor chemical exposure relating to cleaning and or construction/remodeling; and an activity profile looking at exercise during pregnancy.

I understand that no individual information gathered from my participation in the study will be released to others without the written permission.

I understand that participation in this questionnaire may bring up uncomfortable feelings and thoughts about myself and my role in my child’s autism diagnosis. I understand that if these feelings should occur, I will need to evaluate my continued participation in the questionnaire. I understand that I am free to stop at any point along the questionnaire.

I understand that these finding my help professionals to gain a better understanding of the potential triggers of environmental exposure during pregnancy as they may relate to a child later being diagnosed with autism.

I understand that I am not receiving any compensation for my participation. I understand that if the findings of the study are published or presented to a professional audience, no personally identifying information will be released. No individual data will be provided.

I understand that the researcher will answer any questions I have at any time about the project and my participation. I may contact Mischelle Miller-Raftery by email mm@mischellemiller.com or by phone (310) 994-9278. If I have additional questions, I may contact her supervisor Barbara Lackey, PhD., Professor of Psychology, Southern California University at (800) 477-2254. If I have questions about my rights as a research participant, I may contact the Chairperson of the School of Psychology at Southern California University, Dr. Barbara Grimes via email, bgrimes@calsouthern.edu or at (800) 477-2254.

I understand to my satisfaction the information in the consent form regarding my participation in the research project. All of my questions have been answered to my satisfaction. I hereby consent to participate in the research described.

* 1. By checking the "I Agree" box, you agree to be a participant in this study.

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