Assent - Chinese

Green Housing Study Child’s ID # ____________

Appendix G - Assent Form

House ID # ____________

CHILD ASSENT FORM

兒童同意書

(Ages 7-12)

（7到12嵗）

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

我們現在要進行有關房屋裏的東西和呼吸情況方面的研究。

Children from around the country who have asthma may join.

全國内有氣喘的兒童都可以參加該研究。

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.

你母親/監護人告訴我們你的醫生診斷出你有氣喘並且你在過去的一年中有呼吸困難，所以我們想邀請你參與這項研究。

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

如果你同意參與這項研究，以下的事情會發生：

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.

我們首先要確定你是否符合參加研究全程。選擇參加的兒童必須參加研究一年。如參加，你必須幾乎每天晚上都在這個家裏睡覺。

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

第一次家訪的時候，我們會問關於你健康的問題

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

我們會測量你的身高和體重。

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.

我們需要知道你是不是對貓，狗，樹，草，蟲和黴菌過敏。因此我們需要從你的手臂上抽兩茶匙的血。 抽血只會在第一次家訪的時候發生。你可能會因爲針頭而感到輕微疼痛。你也可能感到稍微的頭昏和有瘀青。

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.

我們會讓你對一個測量肺部健康的儀器和一個測量你呼氣能力的儀器吹氣。在吹氣過程中，你可能會感到輕微的頭昏，但這種現象不會持久。

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

我們會讓你在家裏用專門的杯子收集你的尿樣。我們會用尿樣來檢查可能會影響你健康的東西。

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

在接下來的一年中，我們會重復三次這樣的檢查，但是只預計有一次抽血。

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.

在一年期間，當你覺得感冒或患流感時，我們會讓你的母親/監護人從你的鼻子和喉嚨取樣。

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

我們在家訪的時候同時會做以下的事情：

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.

我們會用專門的儀器從你家裏的不同房間的空氣中收集粉塵。我們會吸塵清理你的床和廚房。我們會同過對粉塵的檢測來確定化學物對你呼吸的影響。

Why should you join this study?

爲什麽要參加研究？

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.

參與這項研究可能對你的健康有幫助，也可能沒有幫助。但是通過研究我們有可能了解到會有益於其他兒童的信息。你的母親/監護人會收到有關你血樣和呼吸的報告並和你的醫生分享其結果。

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.

你不是必須參加這項研究。你有選擇的權利。你也可以現在同意參加，然後改變主意。如果你中途改變主意，你只需要告訴我們。沒有人會因爲你改變主意而感到不高興。

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

在你同意參與研究之前，我們會對你有的任何疑問進行解答。

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.

如果你想參與這項研究， 請簽名並填寫日期。你會自己保管一份這個文件的備份。

______________________________________________ _____________

Sign your name here簽名 (Printed name) （清楚填寫名字） Date日期

______________________________________________ _____________

Signature of person obtaining Assent 獲得同意權工作人員簽名 Date日期

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Readability = 3^rd Grade level