Attachment I: Online Survey Youth Assent Form
Online Survey
Youth Assent Form
Online Survey Youth Assent Form
Ogilvy Public Relations Worldwide (Ogilvy PR) is doing a study to learn how to teach kids your age about healthy relationships. This study will involve filling out a “survey” (questionnaire). This study is sponsored by the Centers for Disease Control and Prevention (CDC).
We are asking you to fill out one survey. It will take about 10 minutes. If you agree to take part in the survey, here are things you should know:
You do not have to be in this study. If you do take part, you can stop the survey at any time, for any reason.
In the survey, you will be asked how you spend your time, what stores you shop at, and what types of media you use (for example, about specific radio stations, magazines, and/or Web sites). You 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.
You will not be asked about your own friendships or dating relationships.
You might feel uncomfortable answering questions about how you spend your time. You can choose not to answer any question, at any time.
As you answer the survey questions, we will collect your answers. Only the study staff will see your responses. The data will be erased after the study is over.
Your name and your answers to the questions will be kept secure. What you tell to us will not be shared with your parents, teachers, friends, or anyone else. Your answers will only be used by Ogilvy PR and CDC. No private information, such as your name, will be used.
Ogilvy PR and CDC will write a report based on all of the surveys that are completed. Your name will not be used in any reports or publications about the study.
Your input will help us create better resources about this topic.
Once you complete the survey, you will be able to see how some of your answers compared to answers provided by other kids your age.
Contact Information:
If you have questions about this research, please contact Nancy Accetta, of Ogilvy PR, at 202-729-4167.
Your selection below shows that you understand the above and agree to complete the survey by [date].
( ) I agree to the above [Continue]
( ) I do NOT agree to the above, and will not fill out the survey [Terminate]
Please click on the following link to be redirected to a secure Web site where you will complete the survey.
THANK YOU
| File Type | application/msword |
| File Title | Congratulations |
| Author | Junia Geisler |
| Last Modified By | its7 |
| File Modified | 2010-05-21 |
| File Created | 2010-04-15 |