Attach 7

Student ID: _________

NEXT Plus Student Assent Form

My parent or guardian has said I can be in the project called NEXT Plus. I understand this project is to learn even more about eating, physical activity, sleep, and teens’ risk for heart disease. I also understand that if I agree to take part in the study, some people from The CDM Group will ask me to do some additional activities during my 10^th grade year, the spring semester of my 11^th grade and 12^th grade years, and in the spring of the year after I leave high school. These activities are:

1. Complete an on-line survey listing everything that I eat or drink for three days.

2. Wear a small activity monitor all day for seven days in a row to measure my physical activity.

3. Wear a sleep watch on my wrist for seven days in a row to measure my physical activity and my sleep.

4. Fill out a booklet for seven days to report what activities I do during the time I wear the activity monitor and sleep watch.

5. Arrive at school one day without eating breakfast so the health researcher can take a small amount of blood from my finger after it is pricked. I will then be given breakfast.

A health researcher also will come to my home to do the following:

1. Measure my height, weight, and waist circumference.

2. Take my blood pressure.

3. Teach me how to complete the on-line dietary survey and the physical activity booklet.

4. Ask me to complete a brief survey about the prescription or over-the-counter medicines I take on a regular basis and details about the neighborhood where I live

Being involved in the study is up to me. I can choose to quit or ask to stop at any time. 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 if I agree to participate in NEXT Plus, I will receive the following each year:

1. In 10^th grade I will receive gift cards for $30 for completing the three surveys about my eating, $50 for having my height, weight, and waist measured in my home and my blood drawn, $35 for wearing the activity monitor and sleep watch, and $35 for completing the activity diary for seven days.

2. In 11^th grade I will receive gift cards for $30 for completing the 3-day survey about my eating, $35 for wearing the activity monitor and sleep watch, and $35 for completing the activity diary for seven days.

3. In 12^th grade I will receive gift cards for $30 for completing the 3-day survey about my eating, $35 for wearing the activity monitor and sleep watch, and $35 for completing the activity diary for seven days.

4. In the year after high school, I will receive gift cards for $30 for completing the 3-day survey about my eating, $50 for having my height, weight, and waist measured, my blood pressure taken, and my blood drawn, $35 for wearing the activity monitor and sleep watch, and $35 for completing the activity diary each day.

If I complete all of the components for NEXT Plus, I will receive gift cards for a total of $500.

Year of Participation	Completing dietary recalls for three days	Completing home visit: weight, height, waist circumference and blood draw	Wearing activity monitor and sleep watch for seven days	Completing activity diary for seven days	Total by Year
10th grade	$30 value	$50 value	$35 gift card	$35 gift card	$150 value
11th grade	$30 value	No visit	$35 gift card	$35 gift card	$100 value
12th grade	$30 value	No visit	$35 gift card	$35 gift card	$100 value
After high school	$30 value	$50 value	$35 gift card	$35 gift card	$150 value
Overall Total	$120 value	$100 value	$140 value	$140 value	$500 value

In addition, if I update my contact information each month, I will receive a free music download of my choice.

Finally, I understand that before I turn 18 my parent or guardian and I will receive a copy of my health screening results. You also will let my parents know right away if any of my health screening results are outside of normal values so we can discuss the results with our doctor. Only I, my parents, and the people working on this project will see my information. After I turn 18, only I will receive these results.

 Yes, I want to be in NEXT Plus.

 No, I do not want to be in NEXT Plus.

By signing my name below, I agree to be involved in the NEXT Plus.

_______________________________________________ ____________

Student’s Signature Date

Please PRINT your first and last name below:

PRINTED NAME: _________________________ ___________________________

First Name Last Name

Who are two friends who are most likely to know how we can get in touch with you should you move from your current address? NOTE: We will NOT share your friend’s address, phone number, or email with anyone outside of the NEXT study.

Friend 1:

Name: (please print) __________________________________________

Street Address ______________________________Apt # ____________

City ________________________ State ___________Zipcode ________

Home telephone: _________________

Cell phone: _____________________

Email: _______________________________________________

Friend 2:

Name: (please print) __________________________________________

Street Address ______________________________Apt # ____________

City ________________________ State ___________Zipcode ________

Home telephone: _________________

Cell phone: _________________

Email: _______________________________________________