Student Accelerometry - Assent

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Empowering students to be fit for life.

Founding Partners

Presidential Youth Fitness Program (PYFP) Evaluation

ICF International is working with the Presidential Youth Fitness Program, the Centers for Disease Control and Prevention (CDC) and the Robert Wood John Foundation to learn more about physical education (PE) and physical activity [PYFP SCHOOLS: how well the PYFP program works].

You are being asked to participate because you were interested and your parents said it was okay for you to participate. We want to make sure you understand what is involved in order to participate.

Ten (10) students have been randomly selected from your PE class to participate. We chose students from the group whose parents said it was okay to participate.

If you agree to participate you will be asked to:

• Wear a physical activity monitor that is a small box (accelerometer) around your waist that will tell us how much you move around. It is not able to record any other information such as where you are at any time or what you are doing. All of the information will be kept private. No one will know how much you moved around.

• You will be asked to wear the small box while you are awake for at least four days but wearing everyday would be great.

• You will be asked to wear the monitor over your right hip, either on a belt or clip.

• You will also write down your activities during the day.

The monitor is not waterproof, so it cannot be worn swimming. If a teacher or coach asks that you not wear the monitor, it is okay to take it off. Just place the monitor back on when you are out of practice or out of class.

About 500 students just like you will be asked to where the monitor – including other 6^th graders at your school. We will visit about 22 schools across the country over the next two years.

You can stop wearing the monitor at any time; it is voluntary. Wearing the small box will cause you little or no risk. Whether or not you wear the small box will not affect your grade in this class.

You will get no benefit right away from wearing the monitor. But the overall results will help the PYFP program and other students in the future.

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Students who wear the small box for a week will receive a small non-monetary prize equivalent to $15 for wearing it at the beginning of the semester, and another one equivalent to $35 for wearing it for another week at the end of the semester. Also, students will be entered into a drawing for non-monetary prizes equivalent to $100 for each day they wear the small box. If you wear the monitor for 4 days at the beginning and end of the semester, you will receive 8 entries into the drawing; if you wear the accelerometer every day for a week at the beginning and end of the semester, you will get 14 entries into the drawing. To be counted you should wear the monitor the whole time you are awake or at least 8 hours. You will receive the thank you prize one to two weeks after the monitor is returned.

Do you have any questions?

Will you participate in this project and wear the physical activity monitor?

YES, you will participate.

NO, you will not participate.

Your parents can contact Isabela Lucas, Project Manager for the PYFP Evaluation, at ICF International at 404-592-2155 with any questions or comments. If you or your parents have any questions about your rights as a participant in this program evaluation, you may contact {ENTER IRB CONTACT} at [NUMBER] or [EMAIL].

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