Child Assent Form Copy

Protocol, PFAS/viral infection, v1.0

Last Revised: August 23, 2021

Reading Level: 5.8

Appendix J – Child Assent Form Copy

COPY OF ASSENT FORM TO KEEP

Evaluating the Association between Serum Concentrations of Per- and Polyfluoroalkyl Substances (PFAS) and Symptoms and Diagnoses of Selected Acute Viral Illnesses

Child Assent Form (7 to <18 years of age)

Scientists at the Centers for Disease Control and Prevention’s (CDC) National Center for Environmental Health (NCEH) and the Agency for Toxic Substances and Disease Registry (ATSDR) are doing a research study. Because you helped us with another study, we would like to know if you want to help with this one too. This form will describe the study so you can decide if you want to be in it. We hope that you will be a part of this study.

_____________________________________________________________________________________

THINGS TO KNOW ABOUT THIS STUDY

WHO IS DOING THIS STUDY: CDC/ATSDR are public health agencies that do research. A research study is when people like scientists, doctors, and teachers collect information to try and answer questions about certain things. If you have any questions about the study, your parents can help answer them, and you can also ask us.

PURPOSE: We are doing this study to try to find out if some things that may be found in people’s bodies could make it easier for them get a virus infection (like a cold or the flu) or make the virus infection worse.

We sent your parents a letter asking if we have their permission for you to be a part of the study. Even if they said it was ok, it is still your choice to make and you can say yes or no.

WHO CAN TAKE PART: ATSDR wants to enroll 2,800 eligible adults (≥ 18 years of age) and 370 eligible children (4-17 years of age) who took part in an earlier ATSDR PFAS study. You will not need any in-person contact with any CDC/ATSDR team members.

EXPECTED TIME IN THE STUDY: About 2-½ hours over a year-long period. Your parent (with your help) is asked to answer five 30-minute surveys at home. The five surveys will be spaced three months apart.

WHAT WILL YOU DO: If you agree and your parents give permission, we ask your parents to answer some questions about you. You can help your parents answer the questions. The questions are on a paper that came in the mail with this letter. If you or your parents need help answering the questions, they can ask us by calling xxx-xxx-xxxx or sending an email with your question to xxx@cdc.gov.

In about 3 months, we will send the next set of questions to answer. There will be three more sets of questions after that. Remember, you can help your parents answer any of the questions.

IT IS YOUR DECISION: You may freely choose to take part in the study. If you start, you can stop at any time. You can refuse to answer any questions. Nothing bad will happen to you or your parent if you don’t join the study.

We’d like to thank you and your parents for taking the time to read this letter and thinking about being in our research study.

Child Assent (7 to <18 years)

Please mark one of the boxes below.

I agree to take part in this research study, and I agree to help my parents complete the surveys to the best of my ability.

¨ Yes ¨ No

If you decide to be a part of this study, and your parents agree, please keep the copy of this form for yourself. You’ll be able to look at this form any time you want to.

Child’s Name/Signature:________________________________________________________________

(Printed)

Date Signed:__________________________________________________________________________

Street Address: ______________________________________________________________________

City: _____________________________________________ State: ________ Zip: ___________

Phone number (area code): __________________________________

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