Consent forms

Attachment N

Consent Forms for Coaches, Parents, and Athletes

[PARENTAL CONSENT FORM]

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

PARENT CONSENT

Improving the Understanding of Traumatic Brain Injury through

Policy and Program Evaluation Research

Researchers

John Foster-Bey, D.L.S., M.B.A., M.P.A. CSR, Incorporated, 703-741-7131.

Robin LaVallee, M.P.P. CSR, Incorporated, 703-741-7141.

Researchers’ Statement

You and your child have volunteered to participate in a CDC research study. The purpose of this consent form is to give you the information you will need to help you decide whether you and your child would like to participate. Please read the form carefully. You may ask questions about the purpose of the research, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. This process is called “informed consent.”

PURPOSE OF THE STUDY

CDC would like to improve the prevention, identification, and management of concussions in youth sports and believes that information from coaches, parents, and youth players would help in understanding the problem. CDC staff are especially interested in how recent state laws and youth athletic organization policies about youth sports-related concussion might be related to knowledge of risks and use of procedures and protocols when a player has suffered a potential concussion.

STUDY PROCEDURES

The study we are asking you to take part in will be conducted prior to and during the Fall 2015 soccer season. At the beginning of the study, you will be asked to fill out a survey online. This survey will ask about your knowledge, behaviors, and attitudes regarding concussions; the type, amount, and resources used for concussion education; your child’s prior history and diagnosis of concussion; and your child’s athletic experience. The survey should take no more than 10 minutes to complete.

For 10 weeks during the soccer playing season, we will send you a weekly email or text message asking you to call into a phone line and report any injuries your child experienced, the number of days your child participated in practice, and the number of days your child played in a game. The questions will take no more than 3 minutes to answer. If your child has a sports injury that may be a concussion, we will follow-up by phone to learn more about it, time off of play, and time when returned to play. One of the study personnel will call you weekly to follow-up on the injury until your child has recovered from reported concussion symptoms. You may refuse to answer any question or item on the questionnaires during the course of the study.

Your participation is voluntary. You do not have to participate, and if you do, you may skip any question you choose not to answer.

RISKS, STRESS, OR DISCOMFORT

Participating in the study poses minimal risk. One potential risk is that you may find some questions to be personal or sensitive. Some people feel that providing information for research is an invasion of privacy. You can choose not to answer questions at any time.

BENEFITS OF THE STUDY

Participation in this study may make you more aware of the symptoms of sports concussions. The study will also help CDC to assess the effectiveness of state laws and youth athletic organization polices in reducing the number of youth athletes who return to play with concussion symptoms, the general knowledge and understanding of concussions, and the effectiveness of education and training about concussions.

SOURCE OF FUNDING

This study is funded by the Centers for Disease Control and Prevention (CDC).

CONFIDENTIALITY OF RESEARCH INFORMATION

Your responses to the survey will be kept secure and separate from any personally identifiable information. You and your child’s responses will never be shared with his or her coach, US Youth Soccer or other parents. However, if your child reports symptoms consistent with a concussion or any responses that affect their health and safety, we will report this to you. Results of the study will only be shared publically in a report describing the overall group enrolled in the study. Participation in this study does not impact your or your child’s participation in activities in US Youth Soccer.

OTHER INFORMATION

You may decline to participate and you are free to withdraw from this study at any time without penalty or loss of benefits to which you are otherwise entitled.

Subject’s statement

This study has been explained to me. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the researchers listed above.

I, _______________________________________, volunteer to take part in this research.

(Printed name of participant)

My child, ____________________________________, may participate in this research.

(Printed name of child)

__________________

Date

[COACH CONSENT FORM]

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

COACH CONSENT

Improving the Understanding of Traumatic Brain Injury through

Policy and Program Evaluation Research

Researchers

John Foster-Bey, D.L.S., M.B.A., M.P.A. CSR, Incorporated, 703-741-7131.

Robin LaVallee, M.P.P. CSR, Incorporated, 703-741-7141.

Researchers’ Statement

Your team has been selected by the CDC to participate in a research study. The purpose of this consent form is to give you the information you will need to help you decide whether to participate. Please read the form carefully. You may ask questions about the purpose of the research, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. When we have answered all your questions, you can decide if you want to be in the study or not. This process is called “informed consent.”

PURPOSE OF THE STUDY

CDC would like to improve the prevention, identification, and management of concussions in youth sports and believes that information from coaches, parents, and youth players would help in understanding the problem. CDC staff are especially interested in how recent state laws and youth athletic organization policies about youth sports-related concussion might be related to knowledge of risks and use of procedures and protocols when a player has suffered a potential concussion.

STUDY PROCEDURES

The study we are asking you to take part in will be conducted in Fall 2015. You will be asked to fill out a survey online. The survey will ask about concussion knowledge, attitudes, and behaviors; history of concussions; and use and awareness of concussion education materials.

The survey should take no more than 10 minutes to complete. Your participation is voluntary. You do not have to participate, and if you do, you may skip any question you prefer not to answer.

RISKS, STRESS, OR DISCOMFORT

Participating in the study poses minimal risk. One potential risk is that you may find some questions to be personal or sensitive. Some people feel that providing information for research is an invasion of privacy. You can choose not to answer questions at any time.

BENEFITS OF THE STUDY

Participation in this study may make you more aware of the symptoms of sports concussions. The study will help CDC to assess the effectiveness of state laws and youth athletic organization policies in reducing the number of youth athletes who return to play with concussion symptoms, the general knowledge and understanding of concussions, and the effectiveness of education and training about concussions.

SOURCE OF FUNDING

This study is funded by the Centers for Disease Control and Prevention (CDC).

CONFIDENTIALITY OF RESEARCH INFORMATION

Your responses to the survey will be kept secure and separate from any personally identifiable information. Results of the study will only be shared publically in a report describing the overall group enrolled in the study. Participation in this study does not impact your participation in activities in US Youth Soccer.

OTHER INFORMATION

You may decline to participate and you are free to withdraw from this study at any time without penalty or loss of benefits to which you are otherwise entitled.

Subject’s statement

This study has been explained to me. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the researchers listed above.

I, _______________________________________, volunteer to take part in this research.

(Printed name of participant)

__________________

Date

[ATHLETE CONSENT FORM]

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

ATHLETE CONSENT

Improving the Understanding of Traumatic Brain Injury through

Policy and Program Evaluation Research

Researchers

John Foster-Bey, D.L.S., M.B.A., M.P.A. CSR, Incorporated, 703-741-7131.

Robin LaVallee, M.P.P. CSR, Incorporated, 703-741-7141.

Researchers’ Statement

You have volunteered to participate in a CDC research study. The purpose of this consent form is to give you the information you will need to help you decide whether to participate. Please read the form carefully. You may ask questions about the purpose of the research, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. This process is called “informed consent.”

PURPOSE OF THE STUDY

CDC would like to improve the prevention, identification, and management of concussions in youth sports and believes that information from coaches, parents, and youth players would help in understanding the problem. CDC staff are especially interested in how recent state laws and youth athletic organization policies about youth sports-related concussion might be related to knowledge of risks and use of procedures and protocols when a player has suffered a potential concussion.

STUDY PROCEDURES

The study we are asking you to take part in will be conducted before and during the Fall 2015 soccer season. At the beginning of the study, you will be asked to fill out a survey online. This survey will ask about your knowledge, behaviors, and attitudes regarding concussions; the type, amount, and resources used for concussion education; your prior history and diagnosis of concussion; and your athletic experience. The survey should take no more than 10 minutes to complete.

For 10 weeks during the soccer playing season, we will send you a weekly email or text message asking you to call into a phone line and report any injuries you experienced, the number of days you participated in practice, and the number of days you played in a game. The questions will take no more than 3 minutes to answer. If you have a sports injury that may be a concussion, we will follow-up by phone to learn more about it, time off of play, and time when returned to play. One of the study personnel will call you weekly to follow-up on the injury until you have recovered from your reported concussion symptoms. You may refuse to answer any question or item on the questionnaires during the course of the study.

Your participation is voluntary. You do not have to participate, and if you do, you may skip any question you choose not to answer.

RISKS, STRESS, OR DISCOMFORT

Participating in the study poses minimal risk. One potential risk is that you may find some questions to be personal or sensitive. Some people feel that providing information for research is an invasion of privacy. You can choose not to answer questions at any time.

BENEFITS OF THE STUDY

Participation in this study may make you more aware of the symptoms of sports concussions. The study will help CDC to assess the effectiveness of state laws and youth athletic organization policies in reducing the number of youth athletes who return to play with concussion symptoms, the general knowledge and understanding of concussions, and the effectiveness of education and training about concussions.

SOURCE OF FUNDING

This study is funded by the Centers for Disease Control and Prevention (CDC).

CONFIDENTIALITY OF RESEARCH INFORMATION

Your responses to the survey will be kept separate from any personally identifiable information. Your responses will never be shared with your coach. However, if you report symptoms consistent with a concussion, we will report this to your parent/guardian. Results of the study will only be shared publically in a report describing the overall group enrolled in the study. Participation in this study does not impact your or your parent’s participation in activities in US Youth Soccer.

OTHER INFORMATION

You may decline to participate and you are free to withdraw from this study at any time without penalty or loss of benefits to which you are otherwise entitled.

Subject’s statement

This study has been explained to me. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the researchers listed above.

I, _______________________________________, volunteer to take part in this research.

(Printed name of participant)

__________________

Date