Assent Form

Attachment L:

ODPHP Physical Activity Guidelines, 2^nd Edition

Assent Form – Focus Groups with Minors

8 to 16 Years of Age

OMB Control Number: 0990-0281

December 21, 2017

Submitted to:

Sherrette Funn

Office of the Chief Information Officer

U.S. Department of Health and Human Services

Submitted by:

Frances Bevington

Strategic Communication and Public Affairs Advisor

Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services

Assent Form – Focus Groups with Minors 8 to 16 Years of Age

CommunicateHealth

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Sponsor / Study Title:	CommunicateHealth / “ODPHP-PAG Audience Research to Understand Needs and Preferences of Parents, Children, and Adolescents”
Principal Investigator:	Corinne Berry
Telephone:	413-582-0425 (24 Hours)
Address:	CommunicateHealth 26 Market St Northampton, MA 01060

This page tells you about the focus group. Please read it and ask us any questions you have.

Question: Who is doing this focus group?

Answer: CommunicateHealth (CH), a health communication company, is doing this focus group. CH is doing the focus group for the Office of Disease Prevention and Health Promotion (ODPHP), which is part of the U.S. Department of Health and Human Services (HHS).

Question: What is the goal of this focus group?

Answer: We are trying to figure out how to talk to kids and teens about being physically active. That’s when you get your body moving, like running or riding a bike. We want to create websites and other tools to help kids and teens be more active.

Question: How can I help?

Answer: We want to learn from what you’ve done and what you think. Hearing what you say in this focus group will help us create tools that help you and people like you be more active.

Question: What will happen in the focus group?

Answer: Your focus group will have people about your age in it, and you’ll be talking about physical activity and being physically active. An adult from CH will lead your focus group.

Corinne Berry

Chesapeake IRB Approved Version 11 Dec 2017

CommunicateHealth

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Question: Do I have to be in this focus group?

Answer: No. You get to decide if you want to be in the focus group or not. You can stop at any time, and you don’t have to answer any questions you don’t want to answer. If you want to leave the focus group after it starts, that’s okay.

Question: How will the people in charge of this project protect my privacy?

Answer: CH will keep your name and all of your personal information private — that means we will not share it with ODPHP or anyone outside of our project team. We will not ask for or keep your personal information. Also, your name will not be shared when we talk to ODPHP about what you say in the focus group.

For more information:

If you or your parents or guardians have questions about this project, contact Dena Fisher, the Project Manager for this project, at [email protected] or (413) 582-0425. 

Assent

I, , agree to be part of this focus group.

I understand that I do not have to be in this focus group. I can leave at any time without causing any trouble. It is okay if I agree to be in the focus group and then change my mind later.

I will let the Office of Disease Prevention and Health Promotion (ODPHP) — which is part of the U.S. Department of Health and Human Services (HHS) — use what I say in the focus group. I understand that what I talk about in the focus group is for research only, and that my name will not be given to anyone who is not part of the focus group team.

I understand that if researchers learn about current or ongoing child abuse or neglect, they will report this to the appropriate authorities.

I agree to ask questions about the focus group if I don't understand something. If I have questions after the focus group is over, I can contact Dena Fisher at [email protected] or at 413-582-0425.

Audio Recording Release

I understand that my voice will be recorded during the focus group. I allow ODPHP to use the recordings of my voice for research purposes only. I understand that my name will not be used for any other purpose.

Corinne Berry

Chesapeake IRB Approved Version 11 Dec 2017

CommunicateHealth

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Summary

I have read this form and understand what it says. I understand that I will get a copy of this form.

Minor’s Name (Print):

Minor’s Signature:

Date:

Corinne Berry

Chesapeake IRB Approved Version 11 Dec 2017