Developing, Marketing, and Evaluation of Eagle Books and
Youth Eagle Books for American Indians and Alaska Natives
PARENTAL CONSENT (PERMISSION) FORM
FORMATIVE GROUPS-YOUTH BOOKS
PURPOSE OF THE PROJECT
We have asked your child to take part in a group talk with 4 to 6 children his or her age. We will ask your child what they think about a book that teaches young people about exercise, healthy eating, and how to prevent diabetes. The title of the book is______________.
Taking part in the group does not mean that your child is at higher risk for diabetes. We want to talk to your child because this book is especially for American Indian children, about your child’s age. What your child tell us will help make sure that young people understand the book and enjoy reading it.
The Native Diabetes Wellness Program at the Centers for Disease Control and Prevention (CDC) is in charge of this project. CDC’s job is to help people stay healthy and safe. Westat is a company that is helping CDC with this project.
PROCEDURES
A trained leader will lead the talk and will ask what your child thinks about the book and how kids can stay healthy.
The talk will last about an hour.
We will not ask your child to talk about their health or your family’s health. We will ask what they think about the book and how kids can stay healthy.
Your child does not have to answer any questions they do not want to.
We will answer all of your child’s questions before the talk starts.
Someone from CDC or Westat will take notes during our talk. We will not write your child’s name in the notes. Later, other people working on this project may read the notes because they could not be here in person. Only people who work on this project will be allowed to see the notes.
RISKS AND BENEFITS
Your child should not be hurt in any kind of way because they took part in this talk. There are no direct benefits to you or your child for taking part in this talk. What your child tells us will help make sure that American Indian children understand and enjoy the book.
COMPENSATION
There is no cost to you or your child for taking part in this talk. You will be given $35 for brining your child and your child will be given a free set of Eagle Books items.
CONFIDENTIALITY (PRIVACY)
Everything your child says today will be kept private, as allowed by law. We will not use your child’s name in anything we write about this talk.
Only people working on this project will be allowed to see the notes from this talk. All notes will be kept in a safe and private place.
RIGHT TO REFUSE OR LEAVE
Your child can choose to take part in this talk or not. It is totally up to you and your child.
Your child does not have to answer any questions they do not want to.
Your child can leave the talk at any time. You will still get $35 for bringing your child, even if they choose not to take part or if they want to leave before the talk is done. Your child will still get the free Eagle Books items, even if they choose not to take part or if they want to leave before the talk is done.
PERSONS TO CONTACT
If you have any questions about the talk, you can call Dr. Lemyra DeBruyn (the CDC person in charge of this project) at 1-505-232-9906. If you have any questions about your child’s rights as a person taking part in this talk or if you feel your child has been hurt by taking part, you can call the CDC Deputy Associate Director for Science at 1-800-585-8814. Leave a message and someone will call back as soon as they can. In your message, please say the CDC project number____________________.
PARENT’S CONSENT
I agree for my child to take part in this group talk. I am at least 18 years old. I am the parent or legal guardian of this child. I have read this form and was given a chance to ask questions. I feel that all of my questions were answered. I know that my child will be asked to talk about the book and how kids can stay healthy. I know that someone from CDC or Westat will take notes. I know that only people working on this project will be able to read the notes from this talk. I know that my child can leave the talk at any time. I was given a copy of this form.
Parent or Guardian Signature: _____________________________________________________
Parent or Guaridan Name (Please Print):___________________________________________
Date: ________________________________________________________________
| File Type | application/msword |
| File Title | ATTACHMENT 3 – INFORMED CONSENT |
| Author | reed-gross_e |
| Last Modified By | Erika Reed-Gross |
| File Modified | 2011-07-07 |
| File Created | 2010-01-28 |