Assent Form

Green Housing Study Child’s ID # ____________

Appendix G - Assent Form

House ID # ____________

CHILD ASSENT FORM

(Ages 7-12)

We want to find out what things in people’s homes affect how they breathe.

Children from around the country who have asthma may join.

You are being asked to join the study because your mother/guardian told us that a doctor said you have asthma and during the past year, you had some trouble breathing.

If you agree to join this study, the following things will happen:

We will figure out if you can join for the whole study. Children who join must be in the study for 1 year. To join, you must sleep almost every day in only this home.

On the first visit, we will ask questions about your health

We will measure how tall you are and how much you weigh.

W e will see if you are allergic to cats, dogs, trees, grass, bugs, and mold. To find out, we will take 2 teaspoons of blood from your arm. This will only happen on the first visit. You may feel a little pain from the needle stick. You may also feel a little dizzy and you may get a small bruise.

We will have you blow air into one machine that measures if your lungs are healthy, and another machine that measures how well you are breathing. During the breathing tests, you might feel a little dizzy, but it won’t last long.

We will ask you to give urine in a cup. We will test the urine for things that might affect your health.

We will repeat all of these measurements three times this year. We will only collect blood once.

During the year, we will also ask your mother/guardian to swab your nose and throat whenever you start to feel like you’re getting a cold or the flu.

When we visit your home we will also do the following:

We will collect dust from the air in different rooms of your home with a special machine. We will also vacuum dust from your bed and in your kitchen. We will test the dust to see if it contains chemicals that can affect your breathing.

Why should you join this study?

Your health may or may not be helped by being in this study. However, we may learn something that will help other children some day. Your mother/guardian will receive a report with results on your blood and how well you breathe to share with your doctor.

You do not have to join this study. It is up to you. You can say okay now, and then change your mind later. If you change your mind later, all you have to do is tell us. No one will be upset if you change your mind.

Before you say yes to be in this study, we will answer any questions you have.

If you want to be in this study, please sign your name and fill in the date. You will get a copy of this form to keep for yourself.

______________________________________________ _____________

Sign your name here (Printed name) Date

______________________________________________ _____________

Signature of person obtaining Assent Date

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Readability = 3^rd Grade level