TIC TOC Opt Out

An injury can happen to anyone at anytime. If you do not wish your child to be enrolled into the TIC-TOC study, complete the form below. Once your child is placed on this list, the researchers will know not to enroll them in this study.

Note that this study will not enroll any child who is 18 years or older.

Tip: After each entry, TAB to the next field.

M-D-Y

Name of parent/guardian:

Email address of parent/guardian:

Number of children (under 18) to add:

Child 1 First Name:

Child 1 Last name:

Child 1 Date of Birth:

M-D-Y

Warning: According to the Date of Birth entered, this child is not between 0-18 years of age. Please doublecheck the date entered. (It must be MM-DD-YYYY).

If the child is over 18, please remove their information from the form. Thank you.

Child 1 City of Residence:

Child 1 State of Residence:

Child 2 First Name:

Child 2 Last name:

Child 2 Date of Birth:

M-D-Y

Child 2 City of Residence:

Child 2 State of Residence:

Child 3 First Name:

Child 3 Last name:

Child 3 Date of Birth:

M-D-Y

Child 3 City of Residence:

Child 3 State of Residence:

Child 4 First Name:

Child 4 Last name:

Child 4 Date of Birth:

M-D-Y

Child 4 City of Residence:

Child 4 State of Residence:

Child 5 First Name:

Child 5 Last name:

Child 5 Date of Birth:

M-D-Y

Child 5 City of Residence:

Child 5 State of Residence:

Child 6 First Name:

Child 6 Last name:

Child 6 Date of Birth:

M-D-Y

Child 6 City of Residence:

Child 6 State of Residence:

Child 7 First Name:

Child 7 Last name:

Child 7 Date of Birth:

M-D-Y

Child 7 City of Residence:

Child 7 State of Residence:

Child 8 First Name:

Child 8 Last name:

Child 8 Date of Birth:

M-D-Y

Child 8 City of Residence:

Child 8 State of Residence:

Child 9 First Name:

Child 9 Last name:

Child 9 Date of Birth:

M-D-Y

Child 9 City of Residence:

Child 9 State of Residence:

Child 10 First Name:

Child 10 Last name:

Child 10 Date of Birth:

M-D-Y

Child 10 City of Residence:

Child 10 State of Residence:

Child 11 First Name:

Child 11 Last name:

Child 11 Date of Birth:

M-D-Y

Child 11 City of Residence:

Child 11 State of Residence:

Child 12 First Name:

Child 12 Last name:

Child 12 Date of Birth:

M-D-Y

Child 12 City of Residence:

Child 12 State of Residence:

Child 13 First Name:

Child 13 Last name:

Child 13 Date of Birth:

M-D-Y

Child 13 City of Residence:

Child 13 State of Residence:

Child 14 First Name:

Child 14 Last name:

Child 14 Date of Birth:

M-D-Y

Child 14 City of Residence:

Child 14 State of Residence:

Child 15 First Name:

Child 15 Last name:

Child 15 Date of Birth:

M-D-Y

Child 15 City of Residence:

Child 15 State of Residence:

A maximum of 15 children can be entered at a time.
If you need to add more, click on the link again. Thank you.

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

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.