tt G3 - Youth Assent

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

Youth Assent Form

We have asked you to take part in a group talk with up to 4 kids your age. We will ask what you think about the Eagle Books. Eagle Books teach children about being healthy and how to prevent diabetes.

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 the Eagle Books are especially for American Indian kids, about your age. So, we want to hear what kids like you think about Eagle Books. What you tell us will help CDC see how the Eagle Books are helping American Indian kids.

The 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 Eagle Books.

• 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 Eagle Books and how to keep kids healthy.

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

• We will answer all of your questions before we start.

• Someone from CDC or Westat will take notes during the talk. We will not write your name in the notes. Later, other people working on this project might read the notes because they could not be here. Only people who work on this project will be able 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 find ways to help kids stay healthy.

COMPENSATION (PAYMENT)

There is no cost to you for taking part in this talk. You will get a small bag of toys and snacks for taking the time to be a part of this talk.

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 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 talk or not. It is all up to you.

• You can leave the talk at any time. Your mom or dad will still get the $70 even if you choose not to take part. Your mom or dad will still get the $70 even if you want to leave before we are 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 Eagle Books and how kids my age 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 talk at any time. I was given a copy of this form.

Youth Signature: _____________________________________________________

Youth Name (Please Print): ___________________________________________

Date: ________________________________________________________________

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