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Attachment G: Online Survey Parental Permission Form

Online Survey Parental Permission Form

PARENTAL PERMISSION FOR YOUTH CAMPAIGN TESTING

On behalf of the Centers for Disease Control and Prevention (CDC), Ogilvy Public Relations Worldwide (Ogilvy PR) is doing a study to learn how to teach kids your child’s age about healthy relationships. Part of this study is an online “survey” (questionnaire). We are asking your child to complete an online survey about healthy relationships. The survey will take about 10 minutes. Below are things you should know if you would like your child to take part in the survey.

• Your child’s participation in this survey is totally voluntary. Your child can stop answering the survey questions at any time, for any reason.

• Your child can choose not to answer any question, at any time.

• In the survey, your child will be asked how he/she spends his/her time, what stores he/she shops at, and what types of media she/she uses (for example, about specific radio stations, magazines, and/or Web sites). Your child may be asked about free things or events for kids and whether they are things you would like to get or would like to attend.

• Your child will not be asked about their own friendships or dating relationships.

• If your child feels uncomfortable answering questions, he/she can choose not to answer any question, at any time.

• Ogilvy PR and CDC will write a report based on all of the surveys that are completed. Your child’s name will not be used in any reports or publications about the study.

• Your child’s name and answers to the questions will be kept secure. No identifying information will be included in the report.

• Your child’s input will help us create better resources on this topic.

• You will receive [amount] HIpoints* in compensation if your child participates in this survey.

• Your child will be able to see how some of his/her responses compared to answers provided by other children who completed the survey.

Contact Information:

This project is sponsored by the CDC. If you have any questions about this project, please call Nancy Accetta, of Ogilvy PR, at 202-729-4167.

( ) I agree to the above [Continue]

( ) I do NOT agree to the above, and will not allow my child to fill out the survey [Terminate]

THANK YOU FOR RESPONDING TO OUR REQUEST FOR YOUR CHILD TO TAKE PART IN THIS SURVEY

If your child is selected to participate, you will receive instructions for your child on completing the survey.

* Note to reviewers: HIpoints are incentive points that can be redeemed for small prizes, and are described in detail in the justification statement. All parents who will see this consent form will be familiar with HIpoints.

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