Parent Permission/Fact Sheet - English

2017 and 2019 National Youth Risk Behavior Survey

Appendix H1

Parental Permission Form and Fact Sheet (English Version)

Form Approved

OMB No. 0920-0493

Expiration Date: XX/XX/XXXX

PARENTAL PERMISSION FORM

Our school is taking part in the {Year} national Youth Risk Behavior Survey (YRBS). This research project is sponsored by the Centers for Disease Control and Prevention (CDC). The survey will ask about the health behaviors of 9th through 12th grade students. The survey will ask about nutrition, physical activity, injuries, and tobacco, alcohol, and other drug use. It also will ask about sexual behaviors that lead to pregnancy and sexually transmitted diseases, including HIV.

Students will be asked to fill out a survey that takes about 35 minutes to complete.

Doing this paper and pencil survey will cause little or no risk to your child. The only potential risk is that some students might find certain questions to be sensitive. The survey has been designed to protect your child's privacy. Students will not put their names on the survey. Also, no school or student will ever be mentioned by name in a report of the results. Your child will get no benefit right away from taking part in the survey. But the results of this survey will help your child and other children in the future. We would like all selected students to take part in the survey, but the survey is voluntary. No action will be taken against the school, you, or your child, if your child does not take part. Students can skip any questions that they do not wish to answer. In addition, students may stop participating in the survey at any point without penalty. If you would like to see the survey, a copy is available in the school office.

State and local school officials and a review board at CDC have approved the survey. You or your child may have questions about your child’s rights as a participant in this research survey. If so, please call the CDC Human Research Protections Office at 1-800-584-8814. Please leave a brief message with your name and phone number. Say that you are calling about CDC protocol #1969. We will return your call as soon as possible.

Please read the section below and check one box. Then, sign the form and return it to the school within 3 days. Please see the other side of this form for more facts about the survey. If your child's teacher or principal cannot answer your questions about the survey, call Kate Flint, Project Director, toll-free at 1-800-675-9727. Thank you.

____________________________________________________________________________________

Child's name: ___________________________________ Grade: ________________________

I have read this form and know what the survey is about.

Please check one box:

YES, my child may take part in this survey.

NO, my child may not take part in this survey.

Parent or guardian’s signature: ____________________________ Date: _________________________

SURVEY FACT SHEET

Q. Why is the {Year} national YRBS being done?

A. The Centers for Disease Control and Prevention (CDC) will use the survey results to help measure how many youth practice health risk behaviors. The survey results also will be used to create school health programs to help reduce these behaviors.

Q. Are sensitive questions asked?

A. Yes. Some questions may be considered sensitive. AIDS, HIV infection, and other sexually transmitted diseases (STDs) are major health problems. Sexual intercourse and injection drug use are among the behaviors known to increase the risk of HIV or other STDs. The only way to determine if adolescents are at risk of becoming infected with HIV or other STDs is to ask questions about these behaviors. Attempted suicide, tobacco use, alcohol and other drug use, and weapon-carrying also may be considered sensitive topics. Questions are presented in a straightforward and sensitive manner in recognition of these topics.

Q. Will student names be used or linked to the surveys?

A. No. The survey has been designed to protect your child’s privacy. Teachers are not involved directly. Specially trained staff will administer the survey in each selected school. Students do not put their name on the survey. When students finish the survey, they place the survey in an envelope and seal it shut. The envelopes are then placed in a large box or envelope.

Q. Do students take the survey more than once to see how their behaviors change?

A. No. Each year a new sample of states, schools, and students is selected. Students who take part one year cannot be tracked because their names are not on the survey.

Q. How was my child selected to be in the survey?

A. About {#} students from approximately {#} schools were selected to take part across the country. One or two classes (about 25 to 50 students) in each grade 9 through 12 were picked randomly to take part in each school.

Q. How long does it take to fill out the survey? Does the survey include a physical test?

A. One class period is needed to fill out the survey, which has {#} multiple-choice questions. The survey does not include a physical test or exam.

Q. Can I see the questions my child will be asked?

A. Yes, a copy of the survey is at your child’s school.

Q. Does the survey have broad national support?

A. Yes. The survey is supported by many major national organizations interested in the health of youth, including: {Insert listing}