Form 2 Child Weight and Height Materials

Attachment 5
CHIS 2009 Subject Contact Materials
5A: Survey Advance Letter
5B: Screener Refusal Conversion Letter
5C: Extended Interview Refusal Conversion Letter
5D: Permission Refusal Conversion Letter
5E: Telephone Introduction and Consent/Assent
Scripts
5F: Child Weight and Height Pilot Recruitment
Materials

Dear Current Resident,
Your household has been selected for this year’s California Health Survey. This
important telephone survey is your opportunity to have your voice heard on health issues.
This survey helps California learn about the health of its people and the problems they
have getting health care. The results may help the people and families in your
community.
Your household is very special because you are part of a scientific sample representing
many other households like yours. We do this survey every two years. Since 2001, more
than 100,000 Californians have talked to us about many different health topics.
We will be calling sometime in the next two weeks and one adult in your household will be
selected for the interview. If you have teenagers (ages 12-17), we will ask to interview one
with permission from a parent. Participation is voluntary. All answers are confidential
and used only for this survey.
Please take a moment to take our call. We are not selling anything or asking for money.
If we call at an inconvenient time, you can suggest a better time for us to call back. To
thank you in advance for taking our call and hearing about this survey, we are enclosing
a $2 bill. This small gift is for you to keep whether or not you decide to participate (this
money is not from State or local taxes).
Thank you for your help.
Sincerely,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note:

If you have questions about the California Health Survey, you can call toll-free 1888-941-2950 or visit our website at www.californiahealthsurvey.org

Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health and the National Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024

Dear Current Resident,
Your household has been selected for this year’s California Health Survey.
This telephone survey is an important opportunity to have your voice heard on
health care issues.
We do this survey every two years. This research helps California learn about
the health of its people and the problems they have getting health care. The
results may be used to help the people and families in your community.
We recently called your home, but it was not a good time for anyone to speak
with us. We know your time is valuable. However, we encourage you to take
just a few minutes to talk to our interviewer when we call again.
Your household is part of a scientific sample representing many other
households like yours. Please take a moment to take our call. If we happen to
call at an inconvenient time, you can suggest a time that is better for you.
If you have any questions, you may call toll free at 1-888-941-2950.
Sincerely,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note: If you want to read more about this survey, you can visit our website at
www.californiahealthsurvey.ucla.edu.

Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health and the National Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024

Dear Current Resident,
We recently talked on the telephone with someone in your home who has been
selected to be part of the California Health Survey. I do not know that person’s
name because this is a confidential survey and names cannot be released.
The person we talked to chose not to do the interview or not to finish it. We
respect that decision since the interview is voluntary. However, I kindly ask
him or her to please reconsider.
You are part of a scientific sample representing many others like yourself. You
are important in making a complete picture of the people of California. The
results may be used to improve health care and help your community.
One of our interviewers from Westat, the survey firm making the telephone
calls, will call again. I want to give the selected person one more opportunity to
be part of this important survey. If necessary, our interviewer can make an
appointment for a more convenient time.
Please take a moment to talk with us. If you have any questions, you may call
toll free at 1-888-941-2950.
Sincerely,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note: If you want to read more about this survey, you can visit our website at
www.californiahealthsurvey.ucla.edu.

Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health and the National Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024

Dear Parent or Guardian,
We recently did a telephone interview with an adult in your household. I want
to thank that person for his or her time. We also selected one teenager
between age 12 and 17 to be interviewed. However, the parent or guardian did
not give us permission to interview their teenager. We respect that decision
and will not speak with anyone under 18 years old without permission.
I want to ask the parent or guardian to please reconsider. Our survey results
may help to improve the health of young people in your community. Your
teenager is important. She or he is part of a scientific sample representing
many other similar young people.
One of our interviewers from Westat, the survey firm making the telephone
calls, will call again. We will again ask for permission to interview the selected
teenager. This voluntary interview only takes about 15 minutes. We can make
an appointment for a convenient time to do it.
If we still cannot get permission, or the selected teenager does not want to do
it, tell the interviewer when we call. We will not call or write again.
If you have any questions, you may call toll-free at 1-888-941-2950.
Yours truly,

Dr. E. Richard Brown
Director, UCLA Center for Health Policy Research
Note: If you want to read more about this survey, you can visit our website at
www.californiahealthsurvey.ucla.edu.

Major funders of this survey include the California Department of Health Care Services, California Department of
Public Health and the National Cancer Institute.
Relevant to Privacy Act Information, the legislative authority for this survey is 42 USC 285.

10960 Wilshire Boulevard, Suite 1550 Los Angeles, CA 90024

Consent Scripts for the California Health Interview Survey
1) Introductory RDD screener script
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles. We
are doing a scientific study about health in California. "
1) "Are you a member of this household and at least 18 years old?"
1. YES................................................ [CONTINUE WITH 3]
2. NO.................................................. [CONTINUE WITH 2]
2) "May I please speak with a household member who is at least 18 years old?"
1. AVAILABLE.................................... [BEGIN SCREENER SCRIPT AGAIN]
2. UNAVAILABLE............................... [END CALL, THANK, AND SET APPOINTMENT]
3. NONE………………………………. .[THANK AND END]
3) "Is this telephone number used for business use only?"
1. YES................................................ [THANK AND END]
2. NO.................................................. [CONTINUE]
I have a few questions to see if someone in your household qualifies for this study. This will only take a
few minutes.
4) "Including yourself, how many adults AGE 18 AND OLDER, currently live in this household?"
_____ NUMBER OF ADULTS
1. MORE THAN ONE...... [USE MODIFIED LAST-BIRTHDAY SELECTION METHOD;
IF SCREENER RESPONDENT = ADULT EXTENDED INTERVIEW RESPONDENT, PROCEED.
OTHERWISE, GO TO SECONDARY SCREENER SCRIPT]
2. NO.................................................. [CONTINUE]
"You do qualify for this study."
[IF NO, ASK: "are you the parent or guardian of a child age 12-17 living in this household?"]
[IF YES, CONTINUE WITH ADOLESCENT SELECTION PROTOCOL.]
[IF NO, GO TO ADULT EXTENDED INTERVIEW CONSENT SCRIPT.]

2) Introductory cell phone only screener script
Hello, my name is {INTERVIEWER NAME}. I am calling for the University of California. We are doing a
scientific study about health in California. If you are currently driving a car or doing any activity that
requires your full attention, I need to call you back at a later time. It will take less than 2 minutes to see if
you qualify for the study. We will send you $5 to thank you for answering these questions.
Are you at least 18 years old?
[PROGRAMMING NOTE: END CALL IMMEDIATELY IF R IS DRIVING OR DOING AN ACTIVITY AND
SET APPOINTMENT].
1) "Are you at least 18 years old?"
1. YES................................................ [GO TO 4]
2. NO.................................................. [CONTINUE WITH 2]
2) "Does an adult, 18 years or older, ever use this phone?"
1

1. AVAILABLE.................................... [BEGIN SCREENER SCRIPT AGAIN]
2. UNAVAILABLE............................... [END CALL, THANK, AND SET APPOINTMENT]
3. NONE………………………………. . [GO TO CLOSE1]
3) “Can we speak to the adult now?”
1. YES................................................ [GO TO 1]
2. NO.................................................. [GO TO CLOSE2]
4) " Is this cell phone your only phone or do you also have a regular telephone at home?"
1. CELL IS ONLY PHONE................................................ [GO TO 7]
2. HAS REGULAR PHONE AT HOME..............................[GO TO ADULT EXTENDED INTERVIEW
CONSENT SCRIPT]
3. NOT RESPONDENT'S CELL PHONE...........................[CONTINUE WITH 5]
4. NOT A CELL PHONE...................... ............................ [GO TO CLOSE2]
5) “Do you live in the same household with the person who owns this phone number?”
1. YES............................................................... [CONTINUE WITH 6]
2. NO................................................................ [THANK, END, CALL BACK]
6) “Does your household have a regular telephone at home?”
1. YES............................................................... [GO TO ADULT EXTENDED INTERVIEW CONSENT
SCRIPT]
2. NO................................................................ [CONTINUE WITH 7]
7) “Is this cell phone used for . . .
1. personal use,..................................................... [CONTINUE]
2. personal and business use,........................................ [CONTINUE]
3. business use only?................................................ [GO TO CLOSE2]
8) “Of all the telephone calls that you receive, are …”
1. All or almost all calls received on cell phones,.................. [CONTINUE]
2. Some received on cell phones and some on regular phones, or....... [CONTINUE]
3. Very few or none on cell phones?.................................. [CONTINUE]
9) "Including yourself, how many adults AGE 18 AND OLDER, currently live in this household?"
_____ NUMBER OF ADULTS
10) "Do any of the adults share this cell phone number?"
1. YES............................. [IF SCREENER RESPONDENT = ADULT EXTENDED INTERVIEWER,
PROCEED. OTHERWISE, USE MODIFIED LAST-BIRTHDAY SELECTION METHOD AND GO TO
ADULT EXTENDED INTERVIEW CONSENT SCRIPT FOR SELECTED R]
2. NO............................... [CONTINUE]
"You do qualify for the study."
[PROGRAMMING NOTE: GO TO ADULT EXTENDED INTERVIEW CONSENT SCRIPT]

2

Verbal Consent and Assent Telephone Scripts for the California Health Interview Survey
1) Consent script for adult extended interview
"{Again}, I am {calling for/or here on behalf of) the University of California at Los Angeles. We are doing a
scientific research study about health that may help improve services in your community. Your
{telephone number/address} was randomly drawn to be in the California Health Survey."
"The interview takes about 30 minutes on average, but may be as short as 20 minutes. There are
questions about your health, diet and exercise, sexual behaviors, and healthcare and insurance.
[PROGRAMMING NOTE: FOR CELL PHONE RESPONDENTS SAY, "We will send you $25 to thank you
for your help with this survey."] [FOR IN-PERSON INTERVIEWS, SAY, "We will give you $25 to thank
you for your help with this survey."]
"This interview is voluntary and confidential. Your answers will be used only for this survey. You can skip
any question, and you can stop at any time."
"Do you have any questions about this?"
[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"The University has very strict safeguards to protect your confidentiality. We have obtained a certificate
from the National Institutes of Health to protect your privacy. If you want, I can give you the name and
toll-free telephone number of the persons at UCLA in charge of the study. Would you like this information
now or can we begin the interview?"
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS: Your
name, address, and telephone number will be erased after the study is completed. The survey data will
be kept in a secure data center, and your answers will only be used to produce total numbers. No
personal information will be released.
IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that may
identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative,
legislative, or other proceedings. The researchers will use the Certificate to resist any demands for
information that would identify you, except for those from personnel of the United States Government for
information that would be used for auditing or evaluation of Federally- funded projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing
information about yourself or your involvement in this research. If you give an insurer, employer, or other
person your written consent to receive research information, then the researchers may not use the
Certificate to withhold that information."]
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office for the
Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE
5. DON'T BEGIN INTERVIEW: Ask, "If another time is more convenient, we can schedule at a better
time."]

3

[FOR IN-PERSON INTERVIEWERS, "You may conduct the interview with a cell phone that I
will provide to you or on your household's landline phone, if you have one. Which do you
prefer?"]
[IN-PERSON INTERVIEWERS WILL SCHEDULE CALL WITH REMOTE TELEPHONE
INTERVIEWERS AND RETURN AFTER CALL IS COMPLETED TO THANK
RESPONDENTS AND PAY $25 CASH INCENTIVE.]
2) Permission script read to the adult respondent or screener respondent:
"{Adolescent’s first name} has {also} been selected for the study. Are you the parent or legal
guardian who can give permission for us to speak with {adolescent’s first name}?"
1. YES................................................ [PROCEED]
2. NO.................................................. [THANK AND END]
"Because this interview is voluntary, I will need to ask {adolescent’s first name} if {he/she} is willing to
do it. However, I need to obtain your consent to talk to {adolescent’s first name} because {he/she} is
under the age of 18."
"I will ask questions about health and health behaviors, such as food, exercise, tobacco, alcohol and
drug use. There are also questions about fighting and violence and sexual behavior. Children and
teens have heard about many of these health issues in the classroom."
"All the information is strictly confidential and will not be released to anyone. {Adolescent’s first
name} can skip any question and can stop the interview at any time. The answers will be used only
for this survey. The interview takes about 15 to 20 minutes."
"Also, we believe that young people tend to feel more comfortable doing the interview when their
parents are not in the same room listening. Do you have any questions?"
[PROGRAMMING NOTE: ANSWER QUESTIONS AND PROCEED.]
"May I have your permission to speak with and interview {adolescent’s first name}?"
"If you’d like more information, I can give you the name and toll-free telephone number of the persons
at UCLA in charge of the survey.”
[PROGRAMMING NOTES:
IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office for
the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. READ VERBAL ASSENT SCRIPT TO ADOLESCENT
5. DON'T BEGIN INTERVIEW: Ask "If another time is more convenient, we can schedule at a better
time."]

3) Assent script read to the selected adolescent respondent:
"Hello, my name is {interviewer name}. I am calling for the University of California at Los Angeles.
We are doing a scientific study about health that may help improve services in your community."
"You were selected by chance for this scientific survey. It is completely voluntary, and the information
you give will be kept confidential. Your answers will be used only for this survey. No names are used
when we summarize what we learn."

4

"I'm going to ask questions about diet and exercise and about tobacco, alcohol, and drugs even if you
don’t use any of these. There are also some questions about fighting and violence and sexual
behavior."
"The interview takes about 15 to 20 minutes. You can skip any questions and stop at any time. Do
you have any questions?"
[ANSWER QUESTIONS AND PROCEED.]
"The University has very strict safeguards to protect your confidentiality. We have obtained a
certificate from the National Institutes of Health to protect your privacy. If you want, I can give you the
name and toll-free telephone number of the persons at UCLA in charge of the study. Would you like
this information now or can we begin the interview?"
[PROGRAMMING NOTES: IF REQUESTS INFORMATION ABOUT PRIVACY SAFEGUARDS:
Your name, address, and telephone number will be erased after the study is completed. The survey
results will be kept in a secure data center, and your answers will only be used to produce total
numbers.
[IF REQUESTS INFORMATION ABOUT NIH CERTIFICATE OF CONFIDENTIALITY:
With a Certificate of Confidentiality, the researchers cannot be forced to disclose information that may
identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative,
legislative, or other proceedings. The researchers will use the Certificate to resist any demands for
information that would identify you, except for those from personnel of the United States Government
for information that would be used for auditing or evaluation of Federally- funded projects.
A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily
releasing information about yourself or your involvement in this research. If you give an insurer,
employer, or other person your written consent to receive research information, then the researchers
may not use the Certificate to withhold that information."]
[PROGRAMMING NOTES: IF REQUESTED:
1. WANTS STUDY INFORMATION: Please contact Dr. E. Richard Brown if you have any questions
about the study. Dr. Brown can be reached toll-free at 1-866-275-2447.
2. WANTS INFORMATION ABOUT RIGHTS OF RESEARCH SUBJECTS OR THE NIH
CERTIFICATION FOR PROTECTION OF PERSONAL INFORMATION: Please contact the Office for
the Protection of Research Subjects at (310) 825-8714.]
3. BOTH: Provide both contact numbers.
4. BEGIN INTERVIEW – THANK AND CONTINUE
5. DON'T BEGIN INTERVIEW: Ask, "If another time is more convenient, we can schedule at a better
time."]
"Are you in a private enough place so you can answer these questions freely?"

5

{DATE}
Dear {PARENT’S NAME},
Thank you for recently completing the California Health Survey. This important survey collects
information about the health of people throughout California and may help to improve health
services in your community.
We now invite you to participate in a study about your child’s height and weight. If you choose
to participate and complete all of the steps, you will receive a $20 Visa gift card that you can use
anywhere Visa is accepted.
During the child interview, we asked about the height and weight of:
{CHILD’S NAME}, age {CHILD’S AGE}
Along with other information, your child’s height and weight is a very important health
indicator. However, it is often difficult for parents to know their child’s height and weight and
report it accurately over the telephone. The purpose of this study is to find better ways to
measure and report a child’s height and weight. The sponsors of this study are the National
Institute for Child Health and Human Development, the UCLA Center for Health Policy
Research, and Kaiser Permanente.
We hope that you will choose to participate in this important study. If you have any questions
about how to participate, your rights as a study participant, or the authorization to disclose Kaiser
health information, please call toll free 1-877-275-2447.
Sincerely,

Dr. E. Richard Brown
UCLA Center for Health Policy Research

Dr. David Grant
UCLA Center for Health Policy Research

Dr. Nancy Gordon
Kaiser Permanente, Northern California

Dr. Corinna Koebnick
Kaiser Permanente, Southern California

Page 1 of 3
University of California, Los Angeles
PARENT CONSENT TO PARTICIPATE IN RESEARCH
California Health Interview Survey 2009:
California Child Height and Weight Measurement Improvement Study
You and your child are asked participate in a research study conducted by Dr. E. Richard Brown,
Director of the Center for Health Policy Research at the University of California, Los Angeles,
David Grant, PhD, from the UCLA Center for Health Policy Research, Nancy Gordon, PhD,
from Kaiser Permanente Northern California, and Corinna Koebnick, Kaiser Permanente
Southern California.. You and your child were selected as possible participants in this study
because when you completed the telephone portion of the California Health Interview Survey
you told us that your child was enrolled in Kaiser Permanente health insurance. Your
participation in this research study is voluntary.

PURPOSE OF THE STUDY
This study will help us better understand how accurately parents are able to report their child’s
weight and height over the telephone. With your permission we will compare the weight and
height that you provided over the telephone with the weight and height you provide today as well
as the weight and height measured at your child’s last two Kaiser Permanente doctor’s visits.

PROCEDURES
If you and your child volunteer to participate in this study, we will ask you today to:
1.
2.
3.
4.
5.

Measure your child’s height using the included tape-measure.
Weigh your child on a scale.
Write your child’s height and weight measurements on the included report form.
Mail the report form back using the included envelope.
Provide your permission to release height and weight measurements for your child from
Kaiser Permanente’s medical records.

After we receive your child’s weight and height we will, with your permission:
1. Compare the measurements you mailed back with the information you provided over the
telephone.
2. Compare the measurements you mailed back with the height and weight measurements
from your child’s Kaiser Permanente medical records.

POTENTIAL RISKS AND DISCOMFORTS
The potential risks of your participating in this study are small. However, some children may be
uncomfortable or embarrassed about their height and/or weight.
UCLA IRB Number:
Expiration Date:

Page 2 of 3
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
You will not directly benefit from your participation in the research.
The results of the research may help us better understand changes in child height and weight
trends in California and help to develop programs to reduce childhood obesity. The results of the
research may also help us decide how best to collect data on child weight and height in the
future. The data we collect may also be valuable to researchers and others who analyze data
from the California Health Interview Survey and other telephone health surveys.

PAYMENT FOR PARTICIPATION
You and your child will receive a $20 Visa gift card for your participation in this study.

CONFIDENTIALITY
Any information that is obtained in connection with this study and that can be identified with you
and your child will remain confidential and will be disclosed only with your permission or as
required by law. Confidentiality will be maintained by means of separating you personal
information from the height and weight measurements we will use for this study. No
information identifying you or your child will be released by the researchers to anyone.

PARTICIPATION AND WITHDRAWAL
You can choose whether to be in this study or not, and whether or not to allow your child to be in
this study. If you agree to participate and to allow your child to be in this study, you may
withdraw your consent at any time without consequences of any kind.

IDENTIFICATION OF INVESTIGATORS
If you have any questions or concerns about the research, please feel free to contact:
Dr. E Richard Brown
Principal Investigator
1-888-941-2950
10960 Wilshire Blvd., Suite 1550
Los Angeles, CA 90024

UCLA IRB Number:
Expiration Date:

Page 3 of 3
RIGHTS OF RESEARCH SUBJECTS
You may withdraw your consent at any time and discontinue participation without penalty. You
and your child are not waiving any legal rights because of your participation in this research
study. If you have questions regarding your rights as a research subject, contact the Office for
Protection of Research Subjects, UCLA, 11000 Kinross Avenue, Suite 102, Box 951694, Los
Angeles, CA 90095-1694, (310) 825-8714.

SIGNATURE OF PARENT OR LEGAL GUARDIAN
I understand the procedures described above. My questions have been answered to my
satisfaction, and I to participate and to allow my child to participate in this study. I have been
given a copy of this form.
________________________________________
Name of Child
________________________________________
Name of Parent or Legal Guardian
________________________________________
Signature of Parent or Legal Guardian

______________
Date

SIGNATURE OF INVESTIGATOR OR DESIGNEE
In my judgment the subject is voluntarily and knowingly giving informed consent and possesses
the legal capacity to give informed consent to participate in this research study.
________________________________________
Name of Investigator or Designee
________________________________________
Signature of Investigator or Designee

UCLA IRB Number:
Expiration Date:

____________________
Date

AUTHORIZATION TO DISCLOSE KAISER HEALTH INFORMATION
California Health Interview Survey 2009:
California Child Height and Weight Measurement Improvement Study

I understand that Kaiser Permanente will not condition treatment, payment, enrollment, or
eligibility for benefits on my providing or refusing to provide this authorization.
I hereby authorize:

to disclose to:

Kaiser Permanente North/South
{Address}
{City}

UCLA Center for Health Policy Research
10960 Wilshire Blvd., Suite 1550
Los Angeles, CA 90024

Records and information pertaining to:
{NAME OF CHILD}
{ADDRESS}

Date of Birth: {DATE OF BIRTH}
Telephone number: {NUMBER}

DURATION: This authorization shall become effective immediately and shall remain in effect
for 6 months from the date of signature.
REVOCATION: This authorization is also subject to written revocation by the member/patient at
any time. The written revocation will be effective upon receipt, except to the extent that the
disclosing party or others have acted in reliance upon this authorization.
REDISCLOSURE: I understand that the recipient may not lawfully further use or disclose the
health information unless another authorization is obtained from me or unless such use or
disclosure is specifically required or permitted by law.
SPECIFY RECORDS: This authorization is limited to the disclosure of the named child’s two
most recent height and weight measurements obtained by Kaiser Permanente and the dates those
measurements took place. This authorization does not permit disclosure of any other information.
The recipient may use the health information authorized on this form for statistical analyses only.
A copy of this form is as valid as the original.
Member has a right to a copy of this authorization

_________________
Date

___________________________________________
Signature

California Health Interview Survey 2009:
California Child Height and Weight Measurement Improvement Study

Instructions to Participate and Receive a $20 Visa Gift Card
1. Carefully read the Consent to Participate form.
2. Sign the consent form only if you understand and agree with the information on the form.
3. Carefully read the Authorization to Disclose Kaiser Health Information form.
4. Sign the Authorization form only if you understand and agree with the information on the
form.
5. Follow the enclosed directions to measure the height of your child using the paper-tape
measure provided and write the child’s height on the Report Form.
6. Weigh your child on a scale and write the child’s weight on the Report Form.
7. Return the forms in the pre-addressed, postage-paid envelope.
8. After receiving your completed materials, you will receive a $20 Visa Gift Card. Please
allow 6-8 weeks for delivery.

California Health Interview Survey 2009:
California Child Height and Weight Measurement Improvement Study

Report Form

Using the included paper tape measure, my child’s height is:
feet

Using a scale my child’s weight is:
pounds
or
kilograms

inches