6c - Enhanced protocol Youth assent

Enhanced Protocol: Youth Assent Forms

Youth Assent Form for Children Ages 12-17

We are doing a study to learn about physical activity, eating, and tobacco use among young people where you live. Your parent (or caregiver) says that you can be part of this special study. Your answers will help us to make health programs better for young people like yourself.

If you agree to be in this study, we are going to ask you some questions about your eating, physical activity, tobacco use, and whether you are exposed to tobacco smoke. Your parent (or caregiver) will be with you when we ask these questions. For some questions, we will show you a card that has a letter for each answer, and you can answer by giving us the letter that is next to your answer. This way, your parent (or caregiver) will not know what your answer is. We will also measure your height, weight, and waist size with a measuring tape. We will ask you to spit about three times into a tube to collect some of your saliva.

You can ask questions about this study at any time. Also, you don’t have to answer any question you don’t want to answer. If there are certain measurements that you don’t want us to take, you can tell us not to take them. If you decide at any time not to finish, we will stop.

If you sign this paper, it means that you have read this form (or had it read to you) and that you want to be in the study. Being in the study is up to you, and no one will be upset if you don’t sign this paper or if you change your mind later. You will be given $10.00 in cash for your participation in the study.

Sign your name here: ___________________________________________ Date ____________

Print your name here ___________________________________________ Date ____________

Signature of person obtaining assent: ______________________________ Date _____________

Printed name of person obtaining assent: ___________________________ Date _____________

Youth Assent Form for Children Ages 12-17: Accelerometry

We are also asking you to wear a monitor that will keep track of how much time you spend moving around and how much time you spend sitting still over the next 7 days. It is worn on a belt around your waist. It is very small, hard to see, and will not get in the way of your normal everyday activities. It should be taken off before swimming or bathing, and it should only be worn when you’re awake. The monitor is about the size of a small cell phone.

If you agree to join this part of the study, you will receive a $10 gift card after you have worn the monitor for 7 days and it has been mailed back to us. If we look at the monitor data and find that there is not enough information for us to use, we will ask you to wear the monitor again for 7 days. You will still receive the $10 gift card even if you refuse to wear the monitor for a second week.

If you sign this paper, it means that you have read it (or had it read to you) and that you want to be in the study. Being in the study is up to you, and no one will be upset if you don’t sign this paper or if you change your mind later.

Sign your name here: __________________________________________ Date _____________

Print your name here: __________________________________________ Date _____________

Signature of person obtaining assent: ____________________________ Date _____________

Printed name of person obtaining assent: _________________________ Date _____________

Youth Assent Form for Children Ages 7-11

We are doing a study to learn about exercise and eating. Your parent (or caregiver) says that you can be in this study.

If you agree to be in this study, we will:

1. Measure your height, weight, and waist size with a measuring tape.

2. Ask you to spit about three times into a tube to collect some of your spit.

You can ask questions any time. Even though your parent or caregiver said you can be part of this study, you can tell us not to take the measurements. If you decide at any time not to finish, we will stop.

Being in the study is up to you, and no one will be upset if you don’t want to be in this study or if you change your mind later. Your parent (or caregiver) will get $10 if you are in the study. Do you want to be in the study?

Interviewer record child’s response here:

_____Yes _____No Date ____________

Interviewer print child’s name here ________________________________Date ____________

Signature of person obtaining assent: ______________________________ Date _____________

Printed name of person obtaining assent: ___________________________ Date _____________

Youth Assent Form for Children Ages 7-11: Accelerometry

We are also asking you to wear a small machine around your waist. This machine will keep track of how much you move and how much you are still in the next 7 days. It is very small and will not get in the way of what you usually do. You should take it off before you swim or take a bath. You should only wear it when you’re awake.

If you want to join this part of the study, your parent (or caregiver) will receive $10 for you after you have worn the machine for 7 days. If there is not enough information, we will ask you to wear the machine again for 7 days. Your parent (or caregiver) will still receive the $10 gift card even if you do not want to wear the machine for a second week.

Being in the study is up to you, and no one will be upset if you don’t want to be in this study or if you change your mind later. Do you want to be in this part of the study?

Interviewer record child’s response here:

_____Yes _____No Date ____________

Interviewer print child’s name here: _____________________________Date _____________

Signature of person obtaining assent: ____________________________ Date _____________

Printed name of person obtaining assent: _________________________ Date _____________