Parent Accelerometer Consent Form

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Empowering students to be fit for life.

Presidential Youth Fitness Program (PYFP) Evaluation

We will be conducting accelerometry data collection with students in select schools as part of the Presidential Youth Fitness Program (PYFP) Evaluation. We will chose 10 students per 6^th grade PE class to wear an accelerometer for a week. An accelerometer is a small plastic device worn on a belt that measures movement and physical activity during the time it is worn. It is NOT able to record any information about where a person is located or the type of activity and does not have a digital display. Information about your child’s activity will only be available the evaluation team (not to your child, to you or child’s schools or teachers) and will never be identified with his or her name. We will chose students to wear accelerometers at random from the group of students who have their parent’s permission to participate. Wearing an accelerometer for a week will cause little or no risk to your child. Students who are selected and wear an accelerometer for a week will receive a non-monetary prize equivalent to $15 for wearing it at the beginning of the semester, and a non-monetary prize equivalent to $35 for wearing it for another week at the end of the semester. Following each week of data collection, students will also be entered into a drawing for a non-monetary prize equivalent to $100 for each day they wear the accelerometer. If a student wears the accelerometer for all seven days, they will receive seven entries into the drawing. It is important for students participating to wear the accelerometer when they are awake and for at least four days out of the week. Students will also be asked to complete a brief log of activities such as hours in school and out of school, PE class times or hour of sports practice for each week he/she wears the accelerometer. This should take no more than 30 minutes to complete. There is no risk or side effect for participating in accelerometry data collection other than remembering to wear the device.

If you are willing to have your child participate, please complete the section below. If you would like email or text reminders for your child to wear the accelerometer provide an email address or cellphone number below. It is important to note that even if you provide permission for your child to participate, he/she may not be selected because we will randomly select 10 students per 6^th grade PE class who have parent permission to participate.

If your child is selected to participate, he/she may discontinue participation in the accelerometry data collection activities at any time. Participation is voluntary and deciding to participate or not participate will not impact your child’s grade in PE.

-------------------------------------------------------------------------------------------------------------------------------------------------

Do you approve of your child participating in wearing an accelerometer for a week at the beginning of the semester and a week at the end of the semester? Please complete the information below and return to your child’s PE teacher if you approve his/her participation in accelerometry data collection.

YES, my child may take part in wearing an accelerometry data collection.

Child’s name (Print): ___________________________________________________

Parent/Guardian Signature: _____________________________________________________________ Date: _____________________

Parent/Guardian Name: ___________________________________________________________

If you would like email or text reminders about wearing the accelerometers (fill in contact information for the preferred method of communication below):

Email address: _________________________________________ Cell Phone #: _(___)_____- _______________________

If you have any questions or concerns, please contact Isabela R. Lucas, Project Manager for the PYFP Evaluation, at ICF International: [email protected] or 404-592-2155.