NSFG 2009 ATT G3-ConsentForms

ATTACHMENT G3: NSFG CONSENT FORMS

Note: All of these documents are printed on NCHS letterhead, but providing them in that format for this attachment interfered with the page alignment.

ADULT’S PERMISSION FOR INTERVIEW

This interview is part of the National Survey of Family Growth. This research study is being done for the U.S. National Center for Health Statistics. The University of Michigan will do the interviews. The survey has questions on marriage and divorce, having and raising children, health and health care. The information will be used for health services and health education programs in the U.S. The interviewer will only ask questions that apply to you. The interview lasts about 60-80 minutes. Answers to the questions will be entered into a laptop computer.

You will be part of a scientific sample of people. You will represent thousands of other people across the country. Your participation is very important because it will help the study be accurate for people like yourself. For your help in this study, you will receive $40 as a token of appreciation.

By Federal law, the answers you give are confidential and we will take all possible steps to protect your privacy. Your answers will be used for research only. To keep the answers confidential it is important to do the interview in a private setting. This brochure, which you may have seen earlier, answers questions people sometimes ask about the study.

Your help in this study is completely voluntary. Saying yes or no to being in the survey will not change any benefits you get now or in the future. For most people, the survey is interesting and enjoyable. Some of the questions in the interview may be sensitive for some people. You may choose not to answer any question for any reason, and you may stop the interview at any time.

You may have questions about your rights as a participant in this research study. If so, please call the office of the Research Ethics Review Board at the National Center for Health Statistics, toll free, at 1-800-223-8118. Please leave a brief message with your name and phone number. Say that you are calling about Study Number 2006-01. Your call will be returned as soon as possible. If you have other questions about the survey, you may call Dr. William Mosher or Dr. Joyce Abma (toll-free) at NCHS: 1-866-227-8347, or visit the NSFG webpage: www.cdc.gov/nchs/nsfg.htm.

Thank you again for being part of our survey.

I have read the study letter and brochure. I agree to take part in the survey.

I received the $40 token of appreciation.  I refused the $40 token of appreciation. 

_________________________________ ________________________________
Respondent’s Signature Respondent’s Name (PLEASE PRINT)

_________________________________
Interviewer’s Signature

I have read the study letter and brochure. I agree to take part in the survey but do not wish to sign this consent form. 

Interviewer: The respondent has read the study letter and brochure or they have been read to the respondent. The respondent has given oral permission to be interviewed, but does not wish to sign the consent form.

Interviewer’s Signature ­­­­­­­­­________________________________

PARENT’S/GUARDIAN’S PERMISSION FOR INTERVIEW

This interview is part of the National Survey of Family Growth. This research study is being done for the U.S. National Center for Health Statistics. The University of Michigan will do the interviews. The survey has questions on marriage and divorce, having and raising children, health and use of health care, and attitudes and opinions about these topics. The interviewer will only ask questions that apply to your son or daughter’s experience. The information will be used for health services and health education programs in the U.S. The interview lasts about 60 minutes. Answers to the questions will be entered into a laptop computer.

Your son or daughter will be part of a scientific sample. This sample will represent the 20 million teenagers in the United States. His or her participation is very important and will help the study results to be accurate for all teenagers. Your teenager will receive $40 as a token of appreciation for his or her help in this study.

By Federal law, your teenager’s answers are confidential and we will take all possible steps to protect your teenager’s and your family’s privacy. Your teenager’s answers will be used for research only and will not be shared with you or other family members. To keep the answers confidential it is important to do the interview in a private setting. This brochure, which you may have seen earlier, answers questions people sometimes ask about the study.

Giving your permission does not mean that your son or daughter has to do the interview. It just means that we have your permission to ask him or her for the interview. Your son or daughter is free to decide to do the interview or not. Saying yes or no to being in the survey will not change any benefits you or your teenager gets now or in the future. For most people, the survey is interesting and enjoyable. Some of the questions in the interview may be sensitive for some people. Your son or daughter may choose not to answer any question for any reason, and he or she may stop the interview at any time.

You may have questions about your teenager’s rights as a participant in this research study. If so, please call the office of the Research Ethics Review Board at the National Center for Health Statistics, toll free, at 1-800-223-8118. Please leave a brief message with your name and phone number. Say that you are calling about Study Number 2006-01. Your call will be returned as soon as possible. If you have other questions about the survey, you may call Dr. William Mosher or Dr. Joyce Abma (toll-free) at NCHS: 1-866-227-8347, or visit the NSFG webpage: www.cdc.gov/nchs/nsfg.htm.

I have read the study letter and brochure. You may ask my son or daughter if he or she wants to take part in the survey.

_________________________________ ________________________________
Parent’s/Guardian’s Signature Parent’s/Guardian’s Name (PLEASE PRINT)

____________________________________
Son or Daughter’s Name (PLEASE PRINT)

MINOR’S PERMISSION FOR INTERVIEW (AGE 15-17)

We are doing a research study called The National Survey of Family Growth. Your parent or guardian says that you may take part. This study is being done for the U.S. National Center for Health Statistics. The University of Michigan does the interviews. The survey has questions on marriage and divorce, having and raising children, health and health care. We also ask your thoughts about these topics. The interviewer will only ask questions that make sense for you. The information will be used for health services and health education programs for teens and adults. The interview lasts about 60 minutes. Answers will be put into a laptop computer.

You will be part of a sample that represents the teenagers in the U.S. Your help is very important because you represent thousands of others. To thank you for your help in this study, we will give you $40.

By Federal law, the answers you give are confidential and we will take all possible steps to protect your privacy. We will not share them with your parents, other family members or anyone else. They will be used for research only. To keep the answers private we will do the interview in private. This brochure answers questions people sometimes ask about the study.

It’s your choice to do the interview or not. Saying yes or no to being in the survey will not change any benefits you get now or ever. For most people, the survey is interesting and enjoyable. Some of the questions in the interview may be sensitive for some people. You can say no to any question for any reason. You can stop at any time.

You may have questions about your rights as a participant in this research study. If so, please call the office of the Research Ethics Review Board at the National Center for Health Statistics, toll free, at 1-800-223-8118. Please leave a brief message with your name and phone number. Say that you are calling about Study Number 2006-01. Your call will be returned as soon as possible. If you have other questions about the survey, you may call Dr. William Mosher or Dr. Joyce Abma (toll-free) at NCHS: 1-866-227-8347, or visit the NSFG webpage: www.cdc.gov/nchs/nsfg.htm.

If you agree to take part in this study, please sign this form. Thank you again for being part of our survey.

I have read the study letter and brochure. I agree to take part in the survey.

I received the $40 token of appreciation.  I refused the $40 token of appreciation. 

_________________________________ ________________________________
Respondent’s Signature Respondent’s Name (PLEASE PRINT)

_________________________________
Interviewer’s Signature

6