Leveraging technology for the assessment and monitoring of fragile infants with complex congenital heart disease in the community

Please only complete the below form if you have received an invitation to attend an online focus group on Tuesday 27th September 2022.

New Research Study

Project to develop a mobile application for parental assessment and monitoring of a fragile infant with complex congenital heart disease after their first cardiac surgery

Participant #1

Name of participant #1(Required)

First name Last name

Address

Relationship to child(Required)

Mother, Father

Email Address(Required)

We will send your Zoom link to this email

Participant #2

Name of participant #2

First name Last name

Please leave blank if not applicable

Address

Relationship to child(Required)

Mother, Father

Email address(Required)

Child's details

Name and age of your child(Required)

Child’s name Age of child

Name of heart condition(Required)

What surgery has your child had to date?(Required)

Can you confirm that you will attend the Focus Group meeting via MS Teams on 27th September 2022(Required)

Yes

Can you confirm that you will attend the User Study in January/February 2023(Required)

Yes

Video/photo permission consent

Photo/Video Permissions(Required)

Yes I agree to the LHM photo permission statement

No I don’t agree

Little Hearts Matter wishes to film this event to enable us to review the discussion and fully capture everyone’s suggestions of the study, please indicate above your acceptance of this