Attach 5

Student ID: _________

NEXT Generation Health Study

Student Assent Form

My parent or guardian has said I can be in the project called The Next Generation Health Study (NEXT). I understand that this project will ask me about my eating, physical activity, driving, and alcohol, tobacco, and drug use, as well as my relationships with my family and friends. I also understand that if I agree to take part in the study, some people from The CDM Group will ask me to complete some activities during my 10^th grade year, the spring semesters of my 11^th and 12^th grade years, and in the spring of the year after I leave high school. These activities are

1. Filling out a 45-50 minute survey at school in 10^th grade and on-line or by phone in 11^th and 12^th grades, and the year after I leave high school

2. Having my height, weight, and waist measured at my school during 10^th, 11^th, and 12^th grades.

3. Providing a sample of my saliva.

Being involved in the study is up to me. I can choose to quit or ask to stop at any time. Also, if I do not like any of the questions, I do not have to answer them. No one will be upset if I don’t want to be in the project. If I decide not to be in this project, it will not affect my schoolwork, grades, or what my teachers think of me.

I understand that I will receive a gift card for $10.00 for completing the survey this year. If I agree to have my height, weight, and waist measured, too, I will receive another gift card worth $25. If I agree to give a sample of my saliva, I will receive another gift card for $20. If I do all three activities I will receive gift cards for a total of $55. I also understand that I will receive a gift card each time I complete an activity for this study in 11^th and 12^th grades and the year after I leave high school.

1. In 11^th grade I will receive gift cards for $25 for completing the survey and $25 for having my height, weight, and waist measured.

2. In 12^th grade I will receive gift cards for $30 for completing the survey and $25 for having my height, weight, and waist measured.

3. In the year after high school, I will receive a gift card for $40 for completing the survey. My height, weight, and waist will not be measured that year.

Finally, I understand that before I turn 18 if my height or body weight is way below that of other boys or girls my age, my parent or guardian will receive a letter telling them that. Only the people working on this project will see the rest of my information.

Please mark one of the choices below to tell us what you want to do:

 Yes, I want to be in this project but ONLY complete the survey (sign below).

 Yes, I want to be in this project and complete the survey AND the measurements (sign below).

 Yes, I want to be in this project and complete ALL of the activities including the survey, the measurements, and the saliva sample(sign below).

 NO, I don’t want to be in this project.

By signing my name below, I agree to be involved in the NEXT Generation Health Study.

_______________________________________________ ____________

Child’s Signature Date

Please PRINT your first and last name below:

PRINTED NAME: _________________________ ___________________________

First Name Last Name