Att H2 - Parent Consent

Developing, Marketing, and Evaluation of Eagle Books and Youth Eagle Books for American Indians

and Alaska Natives

Parent’s Consent/Permission Form (K- 4 Groups)

PURPOSE OF THE PROJECT

We have asked your child to take part in a group talk with up to 4 children his or her age. We will ask your child what they think about the Eagle Books. The Eagle Books is a group of children’s books about exercise, healthy eating, and how to prevent diabetes.

Taking part in the group discussion does not mean that your child is at higher risk for diabetes. We want to talk to your child because the Eagle Books are especially for American Indian children, about your child’s age. We want to find out what children think about the Eagle Books and what they have learned.

The Native Diabetes Wellness Program (NDWP) at the Centers for Disease Control and Prevention (CDC) is in charge of this project. Part of CDC’s job is to help people stay healthy and safe. Westat is a company that has been hired to help CDC with this project.

PROCEDURES

• A trained leader will lead the talk and will ask what your child thinks about the Eagle Books and what they have learned.

• The talk will last about an hour.

• We will not ask your child to talk about their health or your family’s health. We will ask what they think about the Eagle Books and how the books can help kids stay healthy.

• Your child does not have to answer any questions they do not want to.

• We will answer all of your child’s questions before the talk starts.

• Someone from CDC or Westat will take notes during our talk. We will not write your child’s name in the notes. Later, other people working on this project may read the notes because they could not be here in person. Only people who work on this project will be allowed to see the notes.

RISKS AND BENEFITS

Your child should not be hurt in any kind of way because they took part in this talk. There are no direct benefits to you or your child for taking part in this talk. What your child tells us will help us understand what kids have learned from the Eagle Books.

COMPENSATION (PAYMENT)

There is no cost to you or your child for taking part in this talk. Your child will receive a small bag of toys and snacks for their time.

CONFIDENTIALITY (PRIVACY)

• Everything your child says will be kept private, as allowed by law. We will not use your child’s name in anything we write about this talk.

• Only people working on this project will be allowed to see the notes from this talk. All notes will be kept in a safe and private place.

RIGHT TO REFUSE OR LEAVE

• Your child can choose to take part in this talk or not. It is all up to you and your child.

• Your child does not have to answer any questions they do not want to.

• Your child can leave the talk at any time. You will still receive the $70 if you or your child chooses not to take part or to leave before the talk is done.

PERSONS TO CONTACT

If you have any questions about the talk, you can call Dr. Lemyra DeBruyn (the CDC person in charge of this project) at 1-505-232-9906. If you have any questions about your child’s rights as a person taking part in this talk or if you feel your child has been hurt by taking part, you can call the CDC Deputy Associate Director for Science at 1-800-585-8814. Leave a message and someone will call back as soon as they can. In your message, please say the CDC project number______________.

PARENT’S CONSENT

I agree for my child to take part in this group talk. I am at least 18 years old. I am the parent or legal guardian of this child. I have read this form and was given a chance to ask questions. I feel that all of my questions were answered. I know that my child will be asked to talk about the Eagle Books. I know that someone from CDC or Westat will take notes. I know that only people working on this project will be able to read the notes from this talk. I know that my child can leave the talk at any time. I have been given a copy of this form.

Parent or Guardian Signature: ____________________________________________

Parent or Guaridan Name (Please Print):_____________________________________

Date: ________________________________________________________________