NIDA Fast Track (OMB Cntrl # 0925-0655)- Consent form parents

National Institute on Drug Abuse

Parental Permission Form

I hereby give my consent to the National Institute on Drug Abuse (NIDA) permission for my child, __________________________________, to participate in a web-based survey during the school day or at home as a homework assignment. The survey will be conducted by NIDA’s contractor, Silber and Associates, Clarksville, Maryland. The survey asks for students’ opinions of the website called NIDA for Teens (http://teens.drugabuse.gov), a government resource for students on drug abuse and addiction. The purpose of the survey is to collect customer satisfaction information that the National Institute on Drug Abuse can use to improve the site.

I understand and agree that the results from the survey will be aggregated by the Contractor, so there will be no identification of students in the results, and will become the property of the National Institute on Drug Abuse. I also understand that my child’s name or any other identifying information will not be used or revealed in any way, and that there will be no harm to my child from participation in this survey.

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Name of High School City, State

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Printed Name of Parent or Guardian Date

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Signature of Parent or Guardian if Participant is a Minor Date

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Printed Name of Minor Student Date

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Signature of Minor Student Date

OR, if Student is 18 years of age or older:

I, ___________________________, am 18 years of age and am competent to contract in my own name.

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Printed Name of Student Over 18 Date

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Signature of Student Over 18 Date