Participant Consent

Attachment B: Participant Consent Form

Thank you for agreeing to participate in the beta testing sessions for Rocket Blades—a new mobile gaming application designed to teach children ages 6 to 8 years old about basic concussion prevention. Before we launch Rocket Blades publicly, we would like to solicit input and feedback from potential users and parents of potential users. Specifically, we are interested in learning:

• if the gaming application successfully delivers intended concussion prevention messages;

• if children enjoy playing the game and understand the mechanics and objectives of the gaming application; and

• whether or not parents feel that Rocket Blades is a learning tool they would want to download for their children.

The information you and your child share with us will help CDC determine if the game is ready for launch and will inform how we share the game with others.

During this usability testing session, we will:

1. Ask you a few questions about yourself and your child.

2. Ask your child to play the Rocket Blades game.

3. Ask your child questions about the game, including what they liked about it and what they learned while playing the game.

4. Ask you to provide feedback about your child’s experience with the game and your thoughts about this particular gaming application as an educational tool.

Your child will play the game in one of our testing rooms. One of our testing facilitators will sit in the room with your child. We will ask you to sit in a different room from your child but you will be able to view his or her entire testing session via a video feed.

All information gathered from you and your child during the session today will only be used to guide decisions about the Rocket Blades gaming application. Information will be shared with relevant staff at Banyan Communications and CDC. The entire exercise will take approximately 30-60 minutes to complete.

Your participation is voluntary and both you and your child can choose to stop the process at any time for any reason. You will be offered the opportunity to preview the game before your child plays it, if you would like. When analyzing and reporting the results, no personal identifiers will be linked to the data and your signed consent form will be stored separately.

Upon completion of the beta testing session, you will receive a $40 Amazon gift card as a token of appreciation for your time and participation.

To provide consent for both you and your child to participate in the beta testing session and to allow the use and release of information gathered during the session as described above, please print and sign your name below.

Child’s Name ______________________________ Age___________

Parent’s Name _______________________________________

Parent’s Signature ______________________ Date: _______________________

Public reporting burden of this collection of information is estimated to average 30 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 (0920-1009)