Survey

Step 1 of 9

Consent for Participation in the Pediatric Research Study
The LivLyme Foundation and its researchers request your consent for participation in a pediatric study about Lyme and tick-borne diseases and your personal experience with having a child (or children) with Lyme and tick-borne illnesses. This consent questions ask you to allow the LivLyme Foundation and its researchers to view your responses and comments to enhance understanding of the topic. LivLyme Foundation and researchers will publish written work upon completion of reviewing the responses.

Participation in this study is completely voluntary. If you decide not to participate there will not be any negative consequences nor will it affect any grant applications you have submitted or may submit to the LivLyme Foundation.

The LivLyme Foundation and its researchers will maintain the confidentiality of the research records and/or data.

By submitting this form you are indicating that you have read the above, are over the age of 21, and that you agree to the terms as described. If you have any questions, or would like a copy of this consent letter, please contact the LivLyme Foundation at Research@LivLymeFoundation.org.

Thanking you in advance for your participation!

LivLyme Foundation
Email*
1. I agree to participate in the research study. I understand the purpose and nature of this study, and I am participating voluntarily. I understand that I can withdraw from the study at any time, without any penalty or consequences.*
- Yes
- No
2. I grant permission for my research study to be saved for the purpose of review by LivLyme and its researchers.*
- Yes
- No
3. I grant permission for the data generated from this research study to be used in publications on this topic by LivLyme and its researchers.*
- Yes
- No

	Positive	Negative	Don't Know	N/A
PCR

Lyme disease is on every continent including Antarctica. Scientist found Lyme disease on penguins in Antarctica.

	Always	Usually	Sometimes	Rarely	Never
Does light bother your child?
Does sound bother your child?
Does your child have tremors or twitching?
Does your child have headaches?
Does your child have vision issues?
Does your child black out or faint?
Does your child get nauseous/motion sickness?
Does your child have short-term memory loss?
Does your child have "brain fog?"
Does your child have problems with mobility?
Does your child have shortness of breath?
Does your child take antibiotics?
Does your child take supplements?
Does your child do IVIG or other IV treatments?

	Yes	No
IV Antibiotics
IVIG
IV Treatments (other)

	Negative	Positive	Don't Know	N/A
ELISA
EIA
IFA
C6
Western Blot
Immunoblot

	Positive	Negative	Don't Know	N/A
18
23
28
30
31
34
39
41
45
58
66
83/93

	Full-time	Part-time	N/A
Public
Private
Homeschool

Survey

Step 1 of 9

Consent for Participation in the Pediatric Research Study

General Information

Mom and Child

Medical Information

Medical Testing Information

School

Parents

Tick Bite Information

Survey Conclusion

	Yes	No
Do you believe your child was bitten by a tick?
Did you see the tick that bit your child?
Did you have the tick tested?

	Always	Usually	Sometimes	Rarely	Never
Can your child keep up in school academically?
Does your child thrive in school socially/emotionally?
Is your child teased/bullied for having Lyme/tick-borne diseases?
Does Lyme/tick-borne disease have a negative impact on your child's ability to participate in extra-curricular activities?

	Yes	No
Mother
Father

	Yes	No
Mother
Father