Att I2 & 3_Parental Permission Packet

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PARENTAL PERMISSION FORM

Our school is taking part in the 2017 National Youth Tobacco Survey Pilot Study (NYTS Pilot). This research project is sponsored by the Centers for Disease Control and Prevention (CDC). Students in grades 6 through 12 will be asked to fill out a survey about their tobacco-related beliefs, attitudes and behaviors, intent to use, and exposure to influences that promote or discourage tobacco use. The pilot study is being conducted in order to examine the feasibility of transitioning from a paper-and-pencil questionnaire to a tablet-based administration. Transitioning to a computer based survey may reduce respondent burden in the future.

Students will be asked to fill out a survey that takes one class period to complete.

Doing this electronic survey will cause little or no risk to your child. 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, however 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 project. 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 tracking # 14FED1405220/14FED14052. 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, please call Michael Knight, NYTS Pilot Coordinator, at 1-571.882.729. 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. What is the NYTS?

A. The NYTS is a national survey conducted annually by the CDC to gather nationally representative data for students in grades 6 through 12 for the following tobacco related topics: prevalence of use (cigarettes, smokeless tobacco, cigars, and other tobacco products), knowledge and attitudes, media and advertising, minors’ access and enforcement, school curriculum, secondhand smoke exposure, and cessation.

Q. Why is the 2017 NYTS Pilot being conducted?

A. The purpose of the NYTS Pilot Study is to determine the feasibility of transitioning the paper-and-pencil questionnaire to a tablet-based administration. Transitioning to a computer based survey may reduce respondent burden in the future.

Q. Are sensitive questions asked?

A. No. All questions on the survey relate to student’s attitudes, behaviors, and knowledge about tobacco use, intent to use, exposure to tobacco use, and exposure to tobacco marketing/advertising.

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 field staff will administer the survey in each selected school. Students do not put their name on the survey. When students finish the survey, they submit their confidential results electronically to a secure web-based location.

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

A. About 6,000 students from approximately 60 schools across the country were selected to take part. One or two classes (about 25 to 50 students) in each grade 6 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. 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: American Academy of Pediatrics, American Association of School Administrators, American Cancer Society, American Heart Association, American Lung Association®, American Medical Association, American School Health Association, Association for Middle Level Education, Association of State and Territorial Health Officials, Council of Chief State School Officers, Legacy, National Association of School Nurses, National Association of Secondary School Principals, National Association of State Boards of Education, National Catholic Educational Association, National Education Association Health Information Network, National PTA, National School Boards Association, and SHAPE America – Society of Health and Physical Educators.

This form only needs to be signed and returned if you do NOT want your child to participate.

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PARENTAL PERMISSION FORM

Our school is taking part in the 2017 National Youth Tobacco Survey Pilot Study (NYTS Pilot). This research project is sponsored by the Centers for Disease Control and Prevention (CDC). Students in grades 6 through 12 will be asked to fill out a survey about their tobacco-related beliefs, attitudes and behaviors, intent to use, and exposure to influences that promote or discourage tobacco use. The pilot study is being conducted in order to examine the feasibility of transitioning from a paper-and-pencil questionnaire to a tablet-based administration. Transitioning to a computer based survey may reduce respondent burden in the future.

Students will be asked to fill out a survey that takes less than one class period to complete.

Doing this electronic survey will cause little or no risk to your child. 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, however 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 project. 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 tracking # 14FED1405220/14FED14052. We will return your call as soon as possible.

Please read the section below and check the box only if you do not want your child to take part in the survey. If you check the box “no” 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, please call Michael Knight, NYTS Pilot coordinator, at 1-571.882.729. Thank you.

_________________________________________________________________________________

Child’s name: ____________________________________________________ Grade: _________

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

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

Parent or guardian’s signature: ______________________________­­­_________ Date: _________

SURVEY FACT SHEET

Q. What is the NYTS?

A. The NYTS is a national survey conducted annually by the CDC to gather nationally representative data for students in grades 6 through 12 for the following tobacco related topics: prevalence of use (cigarettes, smokeless tobacco, cigars, and other tobacco products), knowledge and attitudes, media and advertising, minors’ access and enforcement, school curriculum, secondhand smoke exposure, and cessation.

Q. Why is the 2017 NYTS Pilot being conducted?

A. The purpose of the NYTS Pilot Study is to determine the feasibility of transitioning the paper-and-pencil questionnaire to a tablet-based administration. Transitioning to a computer based survey may reduce respondent burden in the future.

Q. Are sensitive questions asked?

A. No. All questions on the survey relate to student’s attitudes, behaviors, and knowledge about tobacco use, intent to use, exposure to tobacco use, and exposure to tobacco marketing/advertising.

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 field staff will administer the survey in each selected school. Students do not put their name on the survey. When students finish the survey, they submit their confidential results electronically to a secure web-based location.

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

A. About 6,000 students from approximately 60 schools across the country were selected to take part. One or two classes (about 25 to 50 students) in each grade 6 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. 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: American Academy of Pediatrics, AASA The School Superintendents Association, American Cancer Society, American Heart Association and American Stroke Association, American Lung Association®, American Medical Association, American School Health Association, Association for Middle Level Education, Association of State and Territorial Health Officials, Council of Chief State School Officers, National Association of School Nurses, National Association of Secondary School Principals, National Association of State Boards of Education, National Catholic Educational Association, National PTA, Society of Health and Physical Educators, and Truth Initiative.