Caregiver Screener

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Caregiver Survey Recruitment Screener

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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 participate in the Caregiver Survey and Young Child 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 complete this in home examination.”

“This study will involve you completing a survey and observing while I collect measurements and saliva from your child. First, I will ask you specific questions about your child’s 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 your child’s recent weight loss/gain or recent illness or medical diagnosis that could affect biometric measurements. We will also ask about recent meals, and whether your child has had any dental work recently. I will then measure your child’s height, weight, waist circumference and collect a saliva sample to determine any exposure to second hand tobacco smoke.

“The survey will take 20 minutes for you to complete and your child’s examination will take approximately 20 minutes to complete. At the end of the examination you will be given $10.00 in cash for your child’s participation and your time. 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 that gives us permission to begin the in-home examination with both you and your child. Please read over carefully and sign once you are finished. If you have any questions and don’t understand everything, please don’t hesitate to ask me.”

Addendum to Caregiver Survey Recruitment Screener

“Your child may also be invited to participate in an additional study in which your child wears an Actigraph GT3XE accelerometer around his/her waist to keep track of active and inactive time over the next 7 days. You will also be provided with a diary to record your child’s physical activities, sedentary activities such as sitting and watching television, and when he/she goes swimming, takes a shower, 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.”