Appendix C5 - Parental Permission Form and Fact Sheet - NYPANS and 24-Hour Recall

C5. Parental Permission Form and Fact Sheet - NYPANS and 24-Hour Dietary Recall (English Version)

Survey and 24-Hour Recall

PARENTAL PERMISSION FORM

Our school is taking part in the National Youth Physical Activity and Nutrition Survey. This research project is sponsored by the Centers for Disease Control and Prevention (CDC). The survey will ask about the physical activity and dietary behaviors of 9th through 12th grade students.

Students will be asked to fill out a survey that takes about 45 minutes to complete, including the time spent receiving instructions. Also, students will be measured for height and weight in privacy. The survey and measurements for height and weight will be done during school. Students in this class will also be asked to participate in three telephone interviews. The purpose of the interviews is to learn about the foods and beverages students consume. The telephone interviews will be done outside of school and take about 20 -30 minutes each. Students will be offered $20 for each interview they complete. Interview data will be shared only with the CDC.

Doing the paper and pencil survey, being measured for height and weight, and being interviewed about the foods and beverages they consume will cause little or no risk to your child. The only potential risk is that some students might be uncomfortable being measured for height and weight. The survey has been designed to protect your child's privacy. 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 may 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 questions that will be asked, a sample questionnaire 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 office of CDC’s Deputy Associate Director for Science at (800) 584-8814. Please leave a brief message with your name and phone number. Say that you are calling about CDC protocol #XXXX. We will return your call as soon as possible.

Please see the other side of this form for more facts about the study. Then, 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. Nancy Brener of the CDC at (770) 488-6184. 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'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 the physical activity and dietary behaviors of high school students. The survey results also will be used to create school health programs to help promote healthy behaviors.

Q. Are sensitive questions asked?

A. In general, questions about physical activity and dietary habits are considered to be minimally sensitive. However, some students may experience some discomfort when being measured for height and weight.

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

A. The survey has been designed to protect your child’s privacy. Students will be asked to write their name on a detachable form within the survey booklet, which will then be removed and collected by specially trained field staff before they answer any questions. Later it will be used to record height and weight. When students finish the paper-and-pencil survey in class, they place the survey in an envelope and seal it shut. The envelopes are then placed in a big box. Students will also be asked to complete a form with their name and telephone number so that interviewers can call them to do the telephone surveys.

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

A. No. Students will not be asked to participate in the survey more than once.

Q. What do the telephone interviews involve, and why are there three of them?

A. About two weeks after taking the in-school survey, students will be contacted for a telephone interview. During the interview, students will be asked about all the foods and beverages they consumed the day before the interview. They will be asked the portion size of what they ate and drank and the time of day that they ate and drank each item. Because eating habits are usually different on the weekend from on the week days, students will be asked to do two interviews for week days and one interview for a weekend day. Each interview will take about 20-30 minutes to complete. Your child will receive $20 for each interview he/she completes.

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

A. About 8,000 students from approximately 130 schools in states all across the country were picked to take part. One class (about 25 students) in each grade 9 through 12 was picked randomly to take part in each school. From some schools, including your child’s school, one class will also be selected to participate in the telephone surveys.

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 120 questions. Data collectors also will measure students’ height and weight in a private location.

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 following organizations support the national YRBS, under the auspices of which this project is being conducted: 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.