Appendix F - YRBS Questionnaire - supplemental docs

F. Youth Risk Behavior Survey Questionnaire Supplemental Documents

F1. Parental Permission Form Distribution Script

F2. Parental Permission Form and Fact Sheet (English Version)

F3. Parental Permission Form and Fact Sheet (Spanish Version)

F4. Parental Permission Form Reminder Notice (English Version)

F5. Parental Permission Form Reminder Notice (Spanish Version)

F6. Questionnaire Administration Guides

F7. Data Collector Confidentiality Agreement

F1. Parental Permission Form Distribution Script

Dear Teacher:

You may wish to read this as you distribute the parental permission forms to encourage student participation in the 2009 national Youth Risk Behavior Survey.

Thank you.

Our class has been selected to participate in the 2009 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention. This survey is designed to focus on health-risk behaviors, such as smoking or alcohol and drug use, that cause problems during both youth and adulthood. Your participation in the survey is very important as you represent thousands of students around the country. Each of you will receive a parental permission form to take home for a parent or guardian to sign. Please bring this form back within three days. You must return this form to take part in the survey. IF YOU DO NOT HAVE A SIGNED PARENTAL PERMISSION FORM, YOU MAY NOT TAKE THE SURVEY.

F2. Parental Permission Form and Fact Sheet (English Version)

PARENTAL PERMISSION FORM

Our school is taking part in the 2009 national Youth Risk Behavior Survey. This research project is sponsored by the Centers for Disease Control and Prevention (CDC). The survey will ask about the health behaviors of 9th through 12th grade students. The survey will ask about nutrition, physical activity, injuries, tobacco, alcohol, and other drug use. It also will ask about sexual behaviors that lead to pregnancy and sexually transmitted diseases, including HIV.

Students will be asked to fill out a survey that takes about 35 minutes to complete.

Doing this paper and pencil survey will cause little or no risk to your child. The only potential risk is that some students might find certain questions to be sensitive. The survey has been designed to protect your child's privacy. Students will not put their names on the survey. Also, no school or student will ever be mentioned by name in a report of the results. Your child will get no benefit right away from taking part in the survey. But the results of this survey will help your child and other children in the future. We would like all selected students to take part in the survey, but the survey is voluntary. No action will be taken against the school, you, or your child, if your child does not take part. Students can skip any questions that they do not wish to answer. In addition, students may stop participating in the survey at any point without penalty. If you would like to see the survey, a copy is available in the school office.

State and local school officials and a review board at CDC have approved the survey. You or your child may have questions about your child’s rights as a participant in this research study. If so, please call the CDC Human Research Protections Office at 1-800-584-8814. Please leave a brief message with your name and phone number. Say that you are calling about CDC protocol #1969. We will return your call as soon as possible.

Please read the section below and check one box. Then, sign the form and return it to the school within 3 days. Please see the other side of this form for more facts about the survey. If your child's teacher or principal cannot answer your questions about the survey, call Dr. Danice Eaton of the CDC at (770) 488-6143. Thank you.

______________________________________________________________________________

Child's name:______________________________________ Grade: ______________

I have read this form and know what the survey is about.

Please check one box:

[ ] YES, my child may take part in this survey.

[ ] NO, my child may not take part in this survey.

Parent or guardian’s signature:_________________________________ Date:_________________

Phone number: ___________________________________

This survey is done under the authority of the Public Health Service Act (42 USC 241).

Survey Fact Sheet

Q. Why is the survey being done?

A. The Centers for Disease Control and Prevention (CDC) will use the survey results to help measure how many youth practice health risk behaviors. The survey results also will be used to create school health programs to help reduce these behaviors.

Q. Are sensitive questions asked?

A. Yes. Some questions may be considered sensitive. AIDS, HIV infection, and other sexually transmitted diseases (STDs) are major health problems. Sexual intercourse and intravenous drug use are among the behaviors known to increase the risk of HIV or other STD. The only way to determine if adolescents are at risk of becoming infected with HIV or other STDs is to ask questions about these behaviors. Attempted suicide, tobacco use, alcohol and other drug use, and weapon-carrying also may be considered sensitive topics. Questions are presented in a straightforward and sensitive manner in recognition of these topics.

Q. Will student names be used or linked to the surveys?

A. No. The survey has been designed to protect your child’s privacy. Teachers are not involved directly. Students do not put their name on the survey. When students finish the survey, they place the survey in an envelope and seal it shut. The envelopes are then placed in a big box

Q. Do students take the survey more than once to see how their behaviors change?

A. No. Each year a new sample of states, schools, and students is picked. Students who take part one year cannot be tracked because their names are not on the survey.

Q. How was my child picked to be in the survey?

A. About 15,000 students from approximately 200 schools in 27 states were picked to take part across the country. One or two classes (about 25 to 50 students) in each grade 9 through 12 were picked randomly to take part in each school.

Q. How long does it take to fill out the survey? Does the survey include a physical test?

A. One class period is needed to fill out the written survey, which has 98 questions. The survey does not include a physical test or exam.

Q. Can I see the questions my student will be asked?
A. Yes, a copy of the survey is at your student’s school.

Q. Does the survey have national support?

A. Yes. The survey is supported by many major national organizations interested in the health of youth. The American Academy of Pediatrics, the American Association for Health Education, the American Association of School Administrators, the American Cancer Society, the American Medical Association, the Association of State and Territorial Chronic Disease Directors, the Association of State and Territorial Health Officials, the Council of Chief State School Officers, the National Association of Chronic Disease Directors, the National Association of State Boards of Education, the National Education Association, the National PTA, the National School Boards Association, and the Society of State Directors of Health, Physical Education and Recreation have provided letters of support. People from over 100 state and local health and education agencies and 19 federal agencies assisted in the development of the survey.

F3. Parental Permission Form and Fact Sheet (Spanish Version)

FORMULARIO DE PERMISO DE LOS PADRES

Nuestra escuela está participando en la Encuesta Nacional 2009 de Comportamientos Riesgosos de los Jovenes (YRBS). Esta investigación es auspiciado por los Centros del Control y la Prevención de las Enfermedades (CDC). Esta encuesta incluye preguntas sobre los comportamientos de salud de los estudiantes en los grados 9 hasta 12. Las preguntas son sobre comportamiento nutritivo; actividad física; las lesiones; y el uso del tabaco, el alcohol, y otras drogas. También, hay preguntas sobre los comportamientos sexuales que resultan en los embarazos y las enfermedades transmitidas sexualmente, incluyendo el VIH.

Les piden a los estudiantes que completan un cuestionario. Necesitan 35 minutos para completarlo.

Contestar este cuestionario de papel y lápiz representa poco o ningún riesgo para su hijo/a. El único riesgo es que a algunos estudiantes, ciertas preguntas les parezcan sensitivas. Los procedimientos de administración de encuesta fueron diseñados para proteger la privacidad de su hijo/a. Los estudiantes no escriben sus nombres en los cuestionarios. Ninguna escuela o estudiante será identificado en los informes que se publiqen. Su hijo/a no recibirá beneficios inmediatos por llenar la encuesta, pero los resultados de esta encuesta ayudarán a su hijo/a y otros en el futuro. Es muy importante que cada estudiante escogido participe, pero la decisión de participar es voluntaria. No le traerá repercusiones a la escuela, a usted, o a su hijo/a si decide que su hijo/a no participe. Los estudiantes pueden omitir algunas preguntas si quieren. También, los estudiantes puede terminar su participación cuando ellos gusten, sin repercusiones. Hay una copia del cuestionario en la oficina de la escuela para revisar.

Oficiales estatales y locales y un comité de revista a CDC han probado la encuesta. Es posible que usted o su niño tiene preguntas sobre sus derechos como un participante en esta investigación. Si es así, por favor, llame a la Oficina de las Protecciones de la Investigación Humana de CDC a (800) 584-8814 Deje un mensaje breve, incluyendo su nombre, su número del teléfono, y el número de protocol CDC #1969. Se le llamará a usted pronto.

Por favor lea la sección abajo. Marque una respuesta apropiada y devuelva el formulario firmado a la escuela en tres días. Hay más información en el reverso de este formulario. Si la maestra de su hijo/a o el principal de su escuela no le pueden contestar sus preguntas sobre la encuesta, puede llamar a Beth Sundberg al 1(866) 877-8130. Muchas gracias por su cooperación.

Nombre de su hijo/a: ___________________________________________ Grado: ___________________

Yo he leído y entiendo este formulario respecto a la encuesta.

Marque una caja por favor:

[ ] Mi hijo/a tiene mi permiso para participar en esta encuesta.

[ ] Mi hijo/a no tiene mi permiso para participar en esta encuesta.

Firma de padre o madre/guardián legal: ____________________________________ Fecha: _________________

Número de teléfono: _____________________

Esta encuesta está dirigida bajo la autoridad de la Ley de Servicios de Salud Pública (42 USC 241).

HOJA DE HECHOS

P. ¿Por qué administra la encuesta?

R. Los Centros del Control y la Prevención de Enfermedades (CDC) usarán los resultados para medir aquellas comportamientos riesgosos con respeto a la salud que practican los adolescentes. Los resultados se usarán para diseñar los programas de educación y otras estrategías para reducir estas conductas.

P. ¿Son las preguntas sensitivas?

R. Sí. Algunas preguntas pueden considerarse sensitivas. El SIDA, el VIH, y otras enfermedades transmitidas sexualmente son problemas de salud mayores. La cópula sexual y el uso de drogas injectadas pueden aumentar el riesgo del VIH y otras enfermedades transmitidas sexualmente. La única manera determinar cuántos adolescentes están en riesgo es preguntarles sobre estos comportamientos. El intento de suicidio; el uso de tabaco, alcohol, y otras drogas; y el portar armas pueden considerarse asuntos sensitivos. A causa de estos asuntos sensitivos, las preguntas serán presentadas en una manera sensitiva y directa.

P. ¿Se usarán los nombres de los estudiantes o podrán ser identificados en los cuestionarios?

R. No. Los procedimientos de administración de encuesta fueron diseñados para proteger la privacidad de su hijo/a. La encuesta será administrada por personas especialmente adiestradas en este campo. Los estudiantes no se ponen sus nombres en los cuestionarios. El estudiante pondrá su cuestionario (que no contiene identificadores o su nombre) en su propio sobre cerrado. Entonces, los sobres se colocarán en una caja grande.

P. ¿Conducirá la encuesta con los mismos estudiantes otra vez en el futuro para estudiar como las practicas cambian?

R. No. Cada año, una nueva muestra de los estados, las escuelas, y los estudiantes se seleccionará. Será imposible identificar a los estudiantes que participen porque no se va a coleccionar información que les identifiquen.

P. ¿Como fue seleccionado a mi hijo/a?

R. En total, 15,000 estudiantes de 200 escuelas en 27 estados fueron seleccionados para la YRBS nacional. Uno o dos clases de estudiantes (alrededor de 25-50 estudiantes) en cada grado 9 -12 se seleccionarán al azar para realizar la encuesta en cada escuela.

P. ¿Cuánto tiempo necesita la encuesta? ¿Hay un examen físico?

R. El cuestionario de papel y lápiz que contiene 98 preguntas será administrado durante un período de clase normal (45 minutos) No hay examen físico.

P. ¿Tiene la encuesta amplio respaldo?

R. La encuesta ha recibido respaldo extenso de muchas organizaciones nacionales interesadas en la salud de jovenes. La Academia Americana de Pediatría; La Asociación Para el Adelanto de la Educación Para la Salud; La Asociación Americana de Administradores Escolares; La Sociedad Americana Contra El Cáncer; La Asociación Médica Americana; Asociación Americana Para la Salud Escólar; La Asociación de Directores Estatales y Territoriales de Promoción de Salud y Educación en Salud Pública; Asociación de Oficiales Estatales y Territoriales de Salud; El Concilio de Oficiales Principales Escolares; El Instituto Para el Desarollo de La Juventud; Asociación Nacional de las Juntas Estatales de Educación; La Asociación Educacional Nacional; El Red de Información Nacional Para los Jovenes; La Asociación Nacional de Padres y Maestros (PTA); La Asociación Nacional de Las Juntas Escolares; y La Sociedad de Directores Estatales Para Salud, Educación Física, y Recreo han proveído cartas de suporta. Representativos de más que 100 agencias de educación estatales y locales y 19 agencias federales han ayudado en el desarollo de la encuesta.

F4. Parental Permission Form Reminder Notice (English Version)

REMINDER

Dear Parent(s):

Your son or daughter’s school is taking part in a national survey of health behaviors.

Recently, a parental permission form was sent to your home. As yet, it has not been returned.

A second copy of the permission form and fact sheet is attached. Please read the form, check the appropriate box, and return it to the school within three days.

Thank you.

F5. Parental Permission Form Reminder Notice (Spanish Version)

RECORDATORIO

La escuela de su hijo/a está participando en una encuesta nacional sobre el comportamiento de riesgo de salud que practica los adolescentes.

Recientemente, un formulario de permiso fue enviado a su hogar. Hasta este momento, no se ha vuelto.

Una copia segunda del formulario está incluido. Por favor lea este formulario, márque la contestación propio y devuélvalo a la escuela a lo mas tardar en tres días.

Muchas gracias.

F6. Questionnaire Administration Guide

DATA COLLECTOR SURVEY ADMINISTRATION GUIDE

YOUTH RISK BEHAVIOR SURVEY

STEP 1 - VERIFY THAT ALL ASSEMBLED STUDENTS HAVE COMPLETED APPROPRIATE PERMISSION FORM PROCESS REQUIRED FOR THIS SCHOOL AND THAT NONPARTICIPATING STUDENTS (IF ANY) HAVE AN ALTERNATE ACTIVITY.

STEP 2 - AFTER STUDENTS ARE SEATED, DISTRIBUTE (OR ASK TEACHERS TO DISTRIBUTE) PENCILS. DO NOT DISTRIBUTE QUESTIONNAIRE BOOKLETS.

STEP 3 - INTRODUCE YOURSELF AND THE SURVEY TO THE CLASS.

Good (morning/afternoon). I’d like to thank each of you for participating in the national Youth Risk Behavior Survey on behalf of the Centers for Disease Control and Prevention (also known as CDC). Participating in this survey is voluntary and your grade in this class will not be affected, whether or not you answer the questions. However, only a limited number of students like yourselves are participating in this survey in schools all over the country. The answers you give are very important so our results are accurate.

I would like to emphasize that this is not a test of you or this school. In order to develop better education programs, educators, and health officials must find out if students like yourselves are engaging in risky behaviors. These behaviors may include sexual behaviors that lead to pregnancy and sexually transmitted diseases, including HIV; alcohol, tobacco, and drug use; lack of physical activity; poor nutritional habits; or behaviors that may lead to unintentional injury or violence.

STEP 4 - DISTRIBUTE QUESTIONNAIRES/STUDENT ENVELOPES. EMPHASIZE PRIVACY/ ANONYMITY.

Throughout the entire survey process, we will maintain strict procedures to protect your privacy and allow for your anonymous participation. Please do not write your name on the questionnaire booklet. Your answers are private and we do not want to know your name. Results of this survey will never be reported by names, class, or school. When you finish the survey, place your survey booklet in the envelope provided, seal it, and leave it on your desk.

PAUSE HERE TO ANSWER ANY QUESTIONS...

STEP 5 - INSTRUCT THE CLASS IN FILLING OUT QUESTIONNAIRE.

Now I would like you to look at the questionnaire. Please take a moment to read the instructions on the front cover of the questionnaire.

(PAUSE)

Use the No. 2 pencil you have been given to fill out this survey. Do not use a pen or some other pencil. Notice that for each question on the survey, there is a corresponding set of ovals. For each question, choose the answer that best fits what you know, feel, or do, then fill in the corresponding oval. If you must change an answer, erase your old answer completely.

When you are finished, look over your booklet to make sure that you haven’t skipped any questions. We have allowed 35 minutes for completing the survey. If you finish before that time, place your survey booklet in the envelope, seal it, and stay seated until I ask you to turn it in. It is important that you answer the questions based on what you really know, believe, and do. Don’t pick a response just because you think that’s what someone wants you to say. Your teacher and I are not allowed to answer any questions. Simply do the best that you can. Please begin.

NOTE TO DATA COLLECTOR:

(DO NOT READ ALOUD TO STUDENTS)

While students are taking the survey, work with the teacher to complete the Data Collection Checklist, complete the Make-up list, and fill out the label on the front of the 10 x 13 class envelope. Remember when calculating the enrollment, please do not count students who are on the rolls but for all practical purposes have dropped out, are on suspension, or are on extended medical absence. Please write down the number of booklets enclosed.

STEP 6 - AT THE END OF CLASS PERIOD, COLLECT QUESTIONNAIRES.

STEP 7 - THANK PARTICIPANTS.

I would like to thank all of you for participating in this survey. The information you have provided will be used to develop better health education programs for students like yourselves all around the nation.

STEP 8 - THANK THE TEACHER.

F7. Data Collector Confidentiality Agreement

CONFIDENTIALITY AND CONFLICT OF INTEREST AGREEMENT

In consideration of my employment with Macro International Inc. (“Macro”):

1. I recognize that during the course of my employment with Macro, I may have access to confidential and/or proprietary information which is the property of Macro and/or its affiliates, clients and/or other contractors, including but not limited to technical and cost proposals, product and project information not in the public domain, personnel files and salaries, financial data including profit and pricing information, marketing plans, customer and vendor lists and cost data. I agree to maintain the confidentiality of this information and will not, without written permission from the President of Macro, disclose any confidential information at any time during or after my employment at Macro. I further agree that I will use no less than a reasonable degree of care to protect Macro’s confidential and/or proprietary information from disclosure.

2. I acknowledge that, except for material in the Public Domain, all notebooks, memoranda, reports, blueprints and drawings, notes, computer program listings and documents of any kind, any computer disk, or tape or other media containing information obtained pursuant to my project/proposal work at Macro or to which I otherwise gain access, are the exclusive property of Macro’s clients. I agree that, except as required for the performance of my Macro responsibilities, I will not remove from Macro premises any such items without the specific knowledge and consent of the President of Macro. Upon the termination of my employment, I will return all materials received from, or created for, Macro during my employment.

3. I acknowledge that all products relating to the business of Macro which result from work I perform in the course of my employment, or which result from the use of Macro’s facilities, equipment, supplies or confidential information, are the exclusive property of Macro, Macro’s clients, or other organizations, such as professional associations or journals. The use of any such Macro or client products outside of Macro requires the written permission of the President of Macro. Where Macro has the right to use such products to obtain patent, copyright, and/or trade secret protection, I agree to assist Macro (at Macro’s expense) to obtain and enforce its legal rights to such products.

4. I agree that during my employment with Macro and for one year thereafter, I will not, directly or indirectly, solicit, or assist others in soliciting, any employee of Macro for the purpose of causing that employee to terminate employment with Macro.

5. I agree that, should I be required by law, regulation, or court order to disclose Macro confidential or proprietary information, I will, prior to making such disclosure, promptly notify the Company in writing in order to facilitate the Company’s seeking a protective order or other appropriate remedy to protect against such disclosure.

6. I agree that, while employed by Macro, I will abide by the terms and provisions of the Company’s policy on Employee Conflicts of Interest, as published in the Macro Employee Handbook and as reiterated below:

Employee Conflicts of Interest

Macro counts on the dedicated efforts of its staff members. The expertise and capabilities of our employees are the essential building blocks of our success. It is important to all of us that our employees commit their talents and energies to our mutual success and not invest them in support of competitive or conflicting interests. For this reason, Macro generally does not permit staff to engage in employment outside of Macro.

Staff members may not engage in outside consulting or other professional services in areas where Macro provides or contracts for services. Staff are expected to avoid participation in activities or relationships that compete with Macro, that support the efforts of a real or potential Macro competitor, or that might impair or even appear to impair the proper performance of staff job responsibilities. Participation in outside activities, whether compensated or not, is considered to be in conflict with employment at Macro whenever that participation—

• Competes with the Company

• Provides services, either directly or in association with others, which are in competition with services Macro currently provides or might offer

• Provides services and assistance to a competitor or a potential competitor of Macro

• Interferes in any way with the employee’s effective performance of his/her Company duties, such as requiring Company time or facilities, or impacting the employee’s availability to perform essential job duties, project assignments or proposal work.

An employee may not use the Company’s facilities or identifications (such as telephone number and address) to operate another business, profession, or any other work on his/her behalf or on behalf of another employer. All services performed for or on behalf of Macro employee are compensated through the salary paid to the employee and may not be billed to Macro on a consultancy basis.

Participation in conflict-of-interest activities can have serious legal consequences both for the staff member and for Macro. If a staff member is unsure of whether or not an outside activity is a conflict of interest, he/she should discuss the activity with his/her Officer. If a circumstance should arise in which an anticipated activity could present a real or apparent potential conflict of interest, the staff member and his/her Officer are required to obtain the approval of Macro’s President prior to the staff member’s engaging in the activity.

Any exceptions to this Confidentiality and Conflict of Interest Agreement requires the expressed, written authorization of the President of Macro.

_________________________________ _________________________________

Employee Signature Printed Name (Date)

Macro International Inc.

BY: _________________________________ ________________________________

Printed Name (Date)