Attach 4C Informed Consent Forms - Parent and Teen

Attachment 4C: Parent and Child Informed Consent Forms

FLASHE COGNITIVE TESTING CONSENT FORM – PARENT/CAREGIVER

We would like to talk with you about a questionnaire Westat is developing called the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey. Westat is conducting this research for the U.S. Dept. of Health and Human Services (DHHS). The survey asks about health-related topics. By taking part in this interview, you are helping us evaluate how easy or difficult the questions are to understand and answer. Your opinions will help us improve the questionnaire.

• Your participation is completely voluntary. You may stop at any time, and you can skip any questions you do not wish to answer.

• All information obtained during this study will be kept private, under the Privacy Act. The information you provide will only be used to develop and improve the questionnaire. We will not share your answers with anyone outside of the FLASHE project research team.

• The interviewer will audio record the discussion and take notes. In addition, project researchers may observe the interview. The researchers will destroy the audio recording as soon as they complete the questionnaire development process.

• The interview should take about an hour and a half.

• The report summarizing the findings will not contain any names or identifying information.

• You will receive $75 cash as a token of our appreciation for completing the session.

• If you have questions about this research, please contact Linda Nebeling, the Principal Investigator at (301-425-2841; nebelinl@mail.nih.gov). If you have questions about your role as a research participant, please contact Sharon Zack, the Westat Institutional Review Board Administrator (301-251-1500; sharonzack@westat.com).

• A copy of this consent form has been provided for your records.

If you agree to participate in this interview, please sign the following statement.

I have read this consent form and understand the proposed project. I consent to participate in this study and to have the interview audio taped.

___________________________________ ___________________________________

Participant’s Signature Researcher’s Signature

___________________________________ ___________________________________

Printed Name Printed Name

___________________________________

Date

FLASHE COGNITIVE TESTING CONSENT FORM – CHILD

We would like to talk with you about a questionnaire Westat is developing called the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey. Westat is conducting this research for the U.S. Dept. of Health and Human Services (DHHS). The survey asks about health-related topics. By taking part in this interview, you are helping us find out how easy or difficult the questions are to understand and answer. Your opinions will help us make the questionnaire better. For all participants under 18 years of age, both the teen participant and a parent or legal guardian must read this form and sign at the bottom to allow the teen to participate. Participants 18 years of age or older do not need a parent’s signature.

• Your participation is completely voluntary. You may stop at any time, and you can skip any questions you do not wish to answer.

• All information obtained during this study will be kept privacy, under the Privacy Act. The information you provide will only be used to develop and improve the questionnaire. We will not share your answers with anyone outside of the FLASHE project research team.

• The interviewer will audio record the discussion and take notes. In addition, project researchers may observe the interview. The researchers will destroy the audio recording as soon as they complete the questionnaire development process.

• The interview should take about an hour and a half.

• The report summarizing the findings will not contain any names or identifying information.

• You will receive $50 cash as a token of our appreciation for completing the session.

• If you have questions about this research, please contact Linda Nebeling, the Principal Investigator at (301-425-2841; nebelinl@mail.nih.gov). If you have questions about your role as a research participant, please contact Sharon Zack, the Westat Institutional Review Board Administrator (301-251-1500; sharonzack@westat.com).

• A copy of this consent form has been provided for your records.

If you agree to the terms of this individual interview, please read the appropriate statement below and sign your name:

PARENT/GUARDIAN: I have read the above information about this research and my child’s rights as a participant. I give my child permission to participate in this individual interview and to have the interview audio taped.

Parent/Guardian Signature Date

Parent/Guardian Printed Name

TEEN PARTICIPANT: I have read the above information about this research and my rights as a participant. I agree to participate in this individual interview and to have the interview audio taped.

Participant Signature Date

Participant Printed Name

Researcher Signature Date

Researcher Printed Name