Consent for Assessment

OMB Clearance Number: 2528-0337

Expires: XX/XX/XXXX

Attachment G: The Child Assessment and The Obesity & Type II Diabetes Risk Assessment Assent

If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing XXXX@XXXX.XXX. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.

Paperwork Reduction Act Burden Statement

This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at XXXX@XXXXX.XXX or call XXX-XXX-XXXX. 

Privacy Act Statement  

Authority:  Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  Evaluation of the Community Choice Demonstration (CCD).  

Routine Use:  The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.  

Disclosure:  Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals. 

SORN ID:  Community Choice Demonstration Evaluation Data Files, HUD/PDR-09  

Note: Some study activities are being funded by the National Institute of Diabetes and Digestive and Kidney Diseases. 

 

We want to tell you about a research study we are doing. A research study is a way to learn information about something. We would like to find out more about how your neighborhood and where you live may affect your health. You are being asked to join the study because you are 10 to 15 years old and your family is participating in the Community Choice Demonstration. Your parent or guardian said it was okay for me to talk with you today. We want to tell you more about the study now.

The name of the study is called Mobility Opportunity Vouchers to Eliminate Disparities (MOVED for short). Two different U.S. government offices are paying for it. One is called the National Institutes of Health (NIH). The other is the U.S. Department of Housing and Urban Development (HUD). Researchers from Johns Hopkins University and Abt Associates are working closely together with these offices to do this research.

Even though your parent or guardian said yes to you being part of this research, you can decide if you want to answer the questions or not. Once you start, you can also skip any question you don’t want to answer. There are no right or wrong answers to my questions. I am interested in your ideas and opinions.

You do not have to join this study. It is up to you. You can say okay now, and you can change your mind later. All you have to do is tell us. No one will be mad at you if you decide not to join the study or if you say it’s ok now but change your mind later.

We may learn something from this study that will help other children live healthy lives in their neighborhood.

If you say yes to joining this study, we will collect your height, weight, and waist measurements. We will then have you complete a short activity on a tablet. We will also ask you questions about your life, what you eat, your physical activity, such as playing sports or walking, your school and neighborhood, your friends, and your mood and feelings. We will collect this information at the beginning of the study and two years later to see if there has been any change.

[For children 12 and older only: Read this paragraph; For children younger than 12: Skip to next paragraph] We will also ask you about your gender and sexual orientation. Remember, you can skip any questions you don’t want to answer.

The whole assessment can take up to 1 hour. You may feel tired or bored when answering survey questions, but we will do our best to get through everything as quickly as we can.

We may also ask you to wear a device on your wrist that tracks your exercise and sleep.

If you decide to be a part of the study, please be honest when you answer the questions. We will keep your answers and other information we collect about you private. Your family members will not be able to hear what we are talking about, and I will not tell them any of your answers. But if keeping the information you tell us private could mean that you or someone else could be hurt, we will need to tell someone whose job it is to protect children. This is to keep you and others safe.

We will share what we learn by writing reports. Your answers will be combined with the answers from other children so no one will be able to identify you in these reports.

Before you say yes to being in this study, we will answer any questions you have. [Answer any questions]

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