Survey Recruitment Screener for Youth

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Youth Survey Recruitment Screener for 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 help us with our study.”

“I am (NAME) with RTI International and we are going to ask you questions about physical activity, healthy eating, and tobacco use among kids in your community.

“First, I will ask you questions about your eating habits, physical activity habits, and tobacco use. Your parent or caregiver will be with you while we ask these questions, but for some questions we will show you a card that has numbers for each answer, and you can answer by giving us the number that is next to the right answer. So your parent will not know the answer you have given. We want to know, for example, how often you eat fresh fruits and vegetables and how much physical activity you do. We will also ask about recent meals, how long ago you smoked tobacco and how much you smoke, if at all, whether you are exposed to tobacco smoke, as well as whether you have had any dental work recently. I will also measure your height, weight and the distance (circumference) around your waist with a measuring tape. We will also ask you to spit into a tube to collect some of your saliva.

“Before we get started I need you to read this form to make sure you agree to be in our study. Once you have read and signed, we will get started. If you decide you do not want to be in the study, you do not have to sign this form. If you have any questions and don’t understand everything, please ask me.”

Addendum to Youth Survey Recruitment Screener for Youth Ages 12-17

We will ask you to wear a special device called an accelerometer that will keep track of how much you move and how much you sit still over the next 7 days. We also ask for you to keep a diary of your daily activities such as when you exercise, when you are sitting, when you get up in the morning, when you go to bed, and when you go swimming or take a shower.”

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