Att I4 - Youth Assent

Developing, Marketing, and Evaluation of Eagle Books and

Youth Eagle Books for American Indians and Alaska Natives

Youth Assent Form (Formative Groups-Youth Book 2)

We have asked you to take part in a group talk with 4 to 6 kids your age. We will ask what you think about a book that teaches young people about exercise, healthy eating, and how to prevent diabetes. The title of the books is ___________________.

Taking part in this group talk does not mean that you are not healthy or that you will get diabetes. We want to talk to you because this book is especially for American Indian children, about your age. We want to make sure that young people understand the book and enjoy reading it.

This Centers for Disease Control and Prevention (CDC) is in charge of this project. CDC’s job is to help people be healthy and safe. Westat is a company that is helping CDC with this project.

PROCEDURES (HOW THE GROUP WILL WORK)

• A trained leader will lead the talk and will ask what you think about the book and how kids can stay healthy.

• The talk will last about an hour.

• We will not ask you to talk about your health or your family’s health. We will ask what you think about the book and how kids can stay healthy.

• You do not have to answer any questions you do not want to.

• We will answer all of your questions before the group starts.

• Someone from CDC or Westat will take notes during our talk. We will not write your 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

You should not be hurt in any kind of way because you took part in this talk. There are no benefits to you or your parents for taking part in this talk. What you tell us will help CDC make sure that young people understand the book and enjoy reading it.

COMPENSATION (PAYMENT)

There is no cost to you for taking part in this talk. You will get a set of Eagle Books items for taking the time to be a part of this talk. Your parents will get $35 for bringing you here today.

CONFIDENTIALITY (PRIVACY)

• Everything you say today will be kept private, as allowed by law. We will not use your 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

• You can choose to take part in this talk or not. It is all up to you.

• You do not have to answer any questions if you do not want to.

• You can leave the talk at any time. You will still get the free Eagle Books items, even if you choose not to take part or if you want to leave before the talk is done. Your parents will still get $35 for bringing you, even if you choose not to take part or if you want to leave before the talk is done.

PERSONS TO CONTACT

If you have any questions about the talk, you or your parents 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 rights as a person taking part in this talk or if you feel you have been hurt by taking part, you or your parents 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_________________.

YOUTH PERMISSION

I agree (say yes) to take part in this group talk today. I have read this form or someone has read it to me. I was able to ask questions. I feel that all of my questions were answered. I know that we will talk about the book_________________ and how boys and girls can stay healthy. 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 I can leave the talk at any time.

Youth Signature: _____________________________________________________

Youth Name (Please Print): ___________________________________________

Date: ______________________________________________________________

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