This page contains instructions and forms for participation of those under the age of 18 and of those responding on behalf of someone whose adverse reaction contributed to their death.


We highly value responses regarding those in these special situations, but the nature of medical research studies makes the associated formal consent procedures mandatory.


Survey Responses Involving Children Under the Age of 18


  1. For survey responses regarding those under the age of 18, we require a printed parent consent form signed by a parent/guardian.  Children who are 7 and older should additionally be given choice regarding participation and also sign an “assent” form to indicate their willingness.  The form(s) must be received by our office before participating in the study. 


  2. Our mailing address and printable consent forms are available from our website's "Special Situations" page at  http://www.fqstudy.info/Fluoroquinolone_Effects_Study/Special_Situations.html.


  3. If the child is between 13 and 17, print the “Parent Consent Form” and “Adolescent Assent Form” found under the heading “Survey Responses Involving Children Under the Age of 18” and subheading “Forms.”  If the child is between 7 and 12, print the “Parent Consent Form” and ”Child Assent Form.”  If the child is between 0 and 6, print the “Parent Consent Form.”


  4. A parent/guardian should sign the parent consent form.  Children 7-12 or 13-17 should complete the appropriate assent form.  Mail the parent consent form and any assent form to the UCSD Fluoroquinolone Effects Study mailing address given on the web page.  Include the parent/guardian's telephone number where requested.  We will contact the parent/guardian when the form(s) are received.  If you prefer, you may contact our office via phone or email, and we can mail paper copies to you.


  5. For your own records, you may print the document entitled “Experimental Subject’s Bill of Rights” and a second copy of the consent/assent form(s), if desired.


  6. A parent/guardian may call our office for further instructions.


  7. Note: In accordance with California law, if you are a teen, we will not report birth control use, drug and alcohol use, pregnancy, or abortion to your parent/guardian.


  8. If you have any questions, you may contact us by email at fqstudy@ucsd.edu or by phone at (858) 558-4950 x201.


  9. Forms:


  10. For survey responses on behalf of children aged 13-17, please submit completed paper copies of these 2 forms:

  11. Parent Consent Form: Parent Consent for Child to Act as a Research Subject.pdf

  12. Adolescent Assent Form: Adolescent Assent to Act as a Research Subject.pdf


  13. For survey responses on behalf of children aged 7-12, please submit completed paper copies of these 2 forms:

  14. Parent Consent Form: Parent Consent for Child to Act as a Research Subject.pdf

  15. Child Assent Form: Child Assent to Act as a Research Subject.pdf


  16. For survey responses on behalf of children aged 0-6, please submit a completed paper copy of this form:

  17. Parent Consent Form: Parent Consent for Child to Act as a Research Subject.pdf


  18. You may also print and retain a copy of this document for your records:

  19. Experimental Subject’s Bill of Rights: Experimental Subjects Bill of Rights English.pdf


  20. Address the forms to:

  21. UCSD Fluoroquinolone Effects Study
    9500 Gilman Dr. Dept. 0995
    La Jolla, CA 92093-0995



Survey Responses for Those Who Had a Fatal Outcome


  1. For survey responses regarding those whose adverse reaction contributed to their death, we require a printed consent form signed by an adult relative.  The form must be completed by a spouse/parent/adult relative of the deceased.  It must be received by our office before participating in the study.


  2. Our mailing address and printable consent forms are available from our website's "Special Situations" page at http://www.fqstudy.info/Fluoroquinolone_Effects_Study/Special_Situations.html.


  3. Under the heading "Survey Responses for Those Who Had a Fatal Outcome" and subheading “Forms,” print the form labeled “Adult Consent Form“.  If you prefer, you may contact our office via phone or email and we can mail a paper copy to you.  A spouse, parent, adult sibling, adult child, or other adult relative of the deceased should complete and sign the form and mail it to the address given on the web page.  Note that the form contains a specific section to be completed for participation on behalf of those having fatal outcomes.  Be sure to include contact information where requested.  We will contact you when the form is received. 


  4. You may print and retain the document entitled “Experimental Subject’s Bill of Rights” and a second copy of the consent form, for your own records, if desired.


  5. If you have any questions, you may contact us by email at fqstudy@ucsd.edu or by phone at (858) 558-4950 x201.


  6. Forms:


  7. For survey responses on behalf of the deceased, please submit completed paper copies of this form:

  8. Adult Consent Form: Adult Consent to Act as a Research Subject.pdf


  9. You may also print and retain a copy of this document for your records:

  10. Experimental Subject’s Bill of Rights: Experimental Subjects Bill of Rights English.pdf


  11. Address the forms to:

  12. UCSD Fluoroquinolone Effects Study

  13. 9500 Gilman Dr. Dept. 0995

  14. La Jolla, CA 92093-0995








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