Att D3 - Consent for School Admin

Developing, Marketing, and evaluatIon of eagle books and youth eagle books for american indians and alaska natives

INFORMED CONSENT (SCHOOL ADMINISTRATOR)

PURPOSE OF THE PROJECT

We have asked you to take part in an interview and share what you think about the Eagle Books, a group of children’s books that teach children about exercise, healthy eating, and how to prevent diabetes. We will also ask you to tell us what they think about the Diabetes Education in Tribal Schools curriculum (or DETS). We want to talk to you because these materials have been especially developed for American Indian children and the schools and communities that serve them.

Taking part in the interview does not mean that you or your students are not healthy or that you or your students have diabetes. The purpose of this group is to find out what school administrators think about the Eagle Books and DETS.

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

PROCEDURES

• A trained interviewer will lead the interview.

• The interview will last about an hour.

• We will not ask you to talk about your personal health or the health of your students. We will ask what you think about the Eagle Books and DETS and how these materials can help kids stay healthy.

• We will answer any questions you have before the interview starts.

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

• Someone from CDC or Westat will take notes during the interview. We will not write your name in the notes. Later, other people working on this project may see the notes because they cannot be here in person. Only people working on this project will be allowed to see the notes.

RISK AND BENEFITS

There should not be any risks to you of any kind because you took part in this interview. There are no direct benefits to you for taking part in this group. What you tell us will help make sure that the Eagle Books and DETS are meeting the needs of American Indian children.

COMPENSATION

There is no cost to you for taking part in this interview.

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 interview.

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

RIGHT TO REFUSE OR LEAVE

• You can choose to take part in this interview. It is voluntary. You do not have to answer any questions you do not want to.

• You can leave the talk at any time.

PERSONS TO CONTACT

If you have any questions about this group, 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 rights as a person taking part in this talk or if you feel you have been hurt by taking part in this talk, 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________________________.

CONSENT

I agree to take part in this interview. I have read this form and I was able to ask questions. I feel that all of my questions were answered. I know that we will talk about the Eagle Books, DETS, and how kids can stay healthy. I know that someone from CDC or Westat will take notes. I know that only people from this project will be able to read the notes from this talk. I know I can leave the interview at any time. I am at least 18 years old. I have been given a copy of this form.

Your Signature: _____________________________________________________

Your Name (Please Print): ___________________________________________

Date: ______________________________________________________________

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