Screening Survey

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Pimavanserin for Behavioral Inflexibility

We are currently enrolling young adults and adolescents with ASD for a research study. To be enrolled in the study, you or your child must meet additional screening criteria which will require a visit to our site at the KU Medical Center.

You do not have to answer any questions you do not want to, and you may stop this survey at any time by closing the browser window.

The BRAIN Lab is recruiting individuals with autism 16- 40 years of age to participate in our study.

The purpose of this study is to test an investigational medicine called pimavanserin for potential benefit on inflexible thinking or rigid-compulsive behavior in adolescents and adults with autism spectrum disorder or ASD. Pimavanserin is experimental, which means that it is being tested and is not approved by the United States Food and Drug Administration, abbreviated 'FDA', for this purpose. Pimavanserin has been approved by the FDA for the treatment of hallucinations and delusions associated with Parkinson's disease. Your participation is expected to last approximately 10 weeks, with a follow-up one week after the last dose. During that time, you will have about 5 study visits to the clinic, with each visit lasting up to 6 hours, and a follow up phone call a week after your last visit to the clinic. If you want to stop participating or the investigators, physicians, or sponsors decide to withdraw you from this study, the study team will conduct an early termination visit which will last approximately 1 hour. The length of time you are in this study and number of study visits depends on your response to the study drug regimen. It may last up to 3 months or more. Instead of the experimental drug, you may be randomized during certain parts of the study to receive a placebo or 'dummy drug' which is used to compare results to the experimental drug.

You will receive $50 per completed visit, and up to $50 per visit for study-related expenses such as travel and parking. If you leave the study early, you will be reimbursed only for visits you complete. You will be reimbursed with a ClinCard at the completion of each study visit, which works like a pre-paid debit card.

Please complete the contact information below.

Synchronize NDR Screener record_id here.

This is an API call to the KUMC NDR Screener project to pull/reserve the next record_id for data sync purposes. It is read-only.

https://redcap.kumc.edu/redcap_v13.7.25//DataEntry/record_home.php?pid=8139&arm=1&id=______

Interviewer:

Date of Phone Screen:

M-D-Y

Your Name:

* must provide value

What is your relationship to the potential participant?
Please choose the best response:

Self I am 18 years or older and do not have a surrogate decision maker, power of attorney, or legal guardian.

Parent with legal guardianship I am a biological or adoptive parent of a person for whom I have surrogate decision making rights, power of attorney, and/or legal guardianship.

Other with legal guardianship or medical power of attorney I am NOT a biological or adoptive parent. I DO have surrogate decision making rights, power of attorney, and/or legal guardianship for a person 18 years of age or older.

Parent of independent adult or without legal guardianship I am a biological or adoptive parent of a person 18 years or older. I DO NOT have surrogate decision making rights, power of attorney, and/or legal guardianship.

Self

Parent with legal guardianship

Other with legal guardianship or medical power of attorney

Parent of independent adult

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Please describe your relationship to the potential participant

Best phone number:

* must provide value

Whose number is this?

Best Time to call:

* must provide value

Morning

Afternoon

Evening

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Can you receive voicemail at this number?

Yes

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Email Address:

What is your preferred method of contact?

Phone

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Current address (Street, City, State, Zip):

Participant's First Name:

* must provide value

Participants Last Name:

* must provide value

Participant's Preferred Name and Pronouns:

Sex

* must provide value

Male

Female

Intersex

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Height:

Weight:

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Participant's Date of Birth:

M-D-Y

Participant's age (in years)

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Is the participant fluent in English (can understand more than 2 step instructions)?

Yes

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How did you find out about this study?

Are you interested in being contacted for future studies of autism and related conditions?

Yes

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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.