Consent Form

National Survey of Children’s Health – Questionnaire Content Research Consent Form

Each year the U.S. Census Bureau conducts many different surveys.  The Census Bureau routinely tests survey questions and materials used for these surveys in order to produce the best information possible. The purpose of this research is to interview parents and caregivers of children aged 3-17 living in the United States to assess their understanding of proposed new questions and response options for the 2024 National Survey of Children’s Health (NSCH).

The U.S. Census Bureau is conducting this survey on behalf of the U.S. Department of Health and Human Services under Title 13, United States Code, Section 8(b), which allows the Census Bureau to conduct surveys on behalf of other agencies. The OMB control number for this study is 0607-0725 (expiration 12/31/23). Without this approval, we could not conduct this study.. We estimate that completing this study will take 30 minutes on average. If you have comments or questions about this study, please email dsmd.sm@census.gov.

In order to have a complete record of your comments, your interview session will be recorded and saved in a secure location.  We will use the recordings to refresh our memories while we make recommendations on improving the materials.  Only staff directly involved in this research will have access to the recordings. The U.S. Census Bureau is required by law to protect your information and is not permitted to publicly release your responses in a way that could identify you.

Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining this much needed information is extremely important to ensure complete and accurate results. After completion of this session, we will send you $25 by USPS Priority Mail for your participation in this study. 

I have volunteered to participate in this Census Bureau study, and I give permission for my recordings to be used for the purposes stated above.

Participant’s signature:

Participant’s Name:

Participant’s Mailing Address:

Title 42 U.S.C. Section 701 (a)(2) allows HRSA MCHB to collect information for the purpose of understanding the health and well-being of children in the United States. Through partner agreements, the United States Environmental Protection Agency (EPA), the United States Department of Health and Human Services’ Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities (HHS/CDC/NCBDDD), the United States Department of Health and Human Services’ Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion (HHS/CDC/NCCDPHP), and the United States Department of Agriculture (USDA) support specific content on the NSCH topical questionnaires. The EPA supports content on climate change and environmental justice under the Clean Air Act Section 103(b)(2). The CDC/NCBDDD supports content on the receipt of training or interventions around the behavioral treatment of attention-deficit disorder and attention-deficit/hyperactivity disorder under the Public Health Service Act, Section 301, 42 U.S.C. § 241. The CDC/NCCDPHP supports content on the nutrition and physical activity of young children under Sections 301(a), 307, and 399G of the Public Health Service [42 U.S.C. §§241(a), 242l, and 280e-11], as amended. The USDA supports content on food sufficiency under the Healthy, Hunger-Free Kids Act of 2010, Pub. L. 111-296. In particular, 42 U.S.C. 1769d(a) authorizes USDA to conduct research on the causes and consequences of childhood hunger included in 1769d(a)(4)(B), the geographic dispersion of childhood hunger and food insecurity.

This study is being conducted under the authority of Title 13 U.S. Code. The OMB control number for this study is 0607-0725. Federal law protects your privacy and keeps your answers confidential under 13 U.S.C. Section 9. Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.