You are invited to take part in a research study of the Late Effects of Congenital Heart Defects on Parent Ratings of Executive Functioning Skills in School Age Children. You were chosen for the study because you are the parent of a child with a Congenital Heart Defect. This form is part of a process called “informed consent” to allow you to understand this study before deciding whether to take part.

This study is being conducted by a researcher named Ashlee R Loughan, who is a doctoral student at Walden University.

Background Information:
The purpose of this study is to determine the executive function profile of children with congenital heart defects (CHD) and compare those who have cyanotic CHD and acyanotic CHD against their peers with no CHD. If executive dysfunction is found among CHD populations, this may suggest the need for early intervention for the CHD children to assist in future academic and life success.

If you agree to be in this study, you will be asked to: Complete a brief demographic and medical history about your child. Complete a brief anonymous survey either by hand or online. This process should take no longer than 15 minutes.

Voluntary Nature of the Study:
Your participation in this study is voluntary. This means that those involved with this study will respect your decision of whether or not you want to be in the study. If you decide to join the study now, you can still change your mind during the study. You have the right to stop at anytime without judgment or penalty. You may skip any questions you do not wish to answer.

Risks and Benefits of Being in the Study:
No risks are expected during the completion of this study. The benefits include assisting to understand the executive functioning of children with CHD.

There is no monetary compensation for participation in this study. A one-page summary of study findings after the study is complete will be mailed to the participants who included their contact information on the demographic questionnaire. If participants wish to remain anonymous, they can choose not to supply identifying information (name & address) on the demographic/medical history form questions.

Any information you provide will be kept confidential. The researcher will not use your information for any purposes outside of this research project. Also, the researcher will not include your address or anything else that could identify you in any reports of the study.

Contacts and Questions:
You may ask any questions you have now. Or if you have questions later, you may contact the researcher via Iff you want to talk privately about your rights as a participant, you can call Dr. Leilani Endicott. She is the Walden University representative who can discuss this with you. Her phone number is 1-800-925-3368, extension 1210. Walden University’s approval number for this study is 09-13-11-0074911 and it expires on September 12, 2012. It is suggested that you keep/print a copy of this consent form for your records.

Statement of Consent:
I have read the above information and I feel I understand the study well enough to make a decision about my involvement. By completing the survey, I am agreeing to the terms described above.