Youth Survey Recruitment Screener for Parent

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Youth Survey Recruitment Screener for Parent/Guardian of Youth Ages 12-17

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

“Thank you for agreeing to allow your son/daughter to participate in the Youth Survey and Biometric Study”.

“I am (NAME) with RTI International and we are conducting this study with funding from the U.S. Centers for Disease Control and Prevention, otherwise known as the CDC. In this study we are interested in health-related information about children between the ages of 3-17 years old. You previously participated in the Adult Targeted Surveillance Survey and agreed to have your child complete this in home survey and examination.“

“This study will involve your child completing a survey as well as an examination to collect physical measurements and a sample of saliva. First, I will ask your child specific questions about his/her behaviors such as nutrition (e.g., typical consumption of various foods and beverages), physical activity habits, and tobacco use and exposure to tobacco smoke; knowledge of and attitudes about programs and policies that have been implemented in schools to prevent and reduce obesity and tobacco use; and recent weight loss/gain or recent illness or medical diagnosis that could affect biometric measurements. I will also ask about recent meals, how long ago your child smoked tobacco and how much your child smokes, if at all, as well as whether your child has had any dental work recently. I will then complete a measure your child’s height, weight, waist circumference, and collect a saliva sample to determine any exposure to second hand smoke. Your child will be asked questions about themselves with a parent/caregiver in attendance; however, for questions that may be sensitive (for example, related to tobacco use) we will get answers from your child by showing your child a card with numbered answer choices and ask your child to give the field interviewer the number or numbers from the card that correspond to his or her answer.

“Completion of the survey and examination will take your child about 40 minutes. At the end of the examination you will be given $10.00 in cash for his/her participation. A child must complete all procedures to get $10.00.

“Do you have any questions?”

“Great. Before we get started here is a copy of the informed consent form stating that you give your child permission to participate in the in-home survey and examination. Your child will also need to sign the Youth Assent form that explains to your child what the study will involve and ask for their assent to participate in the study. Please read over these two documents carefully. You and your child will sign once you are both finished reading the forms. If you have any questions and don’t understand everything, please don’t hesitate to ask me. A copy of these forms will be given to you at the end of the examination.”

Addendum to Youth Survey Recruitment Screener for Parent/Guardian of Youth Ages 12-17

“This portion of the study will involve collecting data on your child’s physical activity and sedentary (inactive) behavior using an Actigraph GT3XE accelerometer. Your child will be asked to wear an accelerometer to collect information on physical activity and sedentary time over the next 7 days. If your child participates in the accelerometry study, we will provide a diary for him/her to record physical activities, sedentary activities such as sitting and watching television, and when he/she goes swimming, takes a shower and wakes up and goes to bed.”

“For completing the accelerometry component of this study, your child will be given an additional $10.00 gift card.”

“If we receive the activity data from your child’s device and find that we do not have at least 5 days of complete data, we will ask that your child wear the accelerometer for another 7 days.”