Attachment 3j
OMB no. 0920-0950
Expires: 12/31/2019
Assurance of confidentiality – All information which would permit identification of an
individual, a practice, or an establishment will be held confidential, will be used for
statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
MEC e-consent proposed screens: 12-17 yo SP
MEC Consent/Assent
PROVIDE MEC CONSENT BROCHURE AND REVIEW PACKET.
[Let’s take a look at a brochure as I explain the exam process to you.]
HAND RESPONDENT THE EXAMINATION CONSENT BROCHURE IN THE LANGUAGE HE/SHE READS.
REVIEW KEY POINTS FROM BROCHURE AND HEALTH MEASUREMENTS LIST, OR READ FORMS OUT LOUD.
REVIEW MEC DIAGRAM AND LAB TESTS ON BLOOD FLYERS AS NECESSARY.
REVIEW KEY POINTS FROM THE CONSENT/ASSENT AND PARENTAL PERMISSION FOR EXAM AT MEC FORM IN THE LANGUAGE HE/SHE READS, OR READ FORM OUT LOUD.
ANSWER ANY RESPONDENT QUESTIONS.
DISPLAY IMAGE OF CONSENT FORM.
LANGUAGE: ENGLISH OMB# 0920-0950
TURN SCREEN TO {PROXY} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.
REVIEW STATEMENTS AND ALLOW RESPONDENT TO MAKE SELECTIONS.
LANGUAGE: ENGLISH OMB# 0920-0950
EXPLAIN THE MEC EXAM AND MEC INTERVIEW RECORDING STATEMENTS. TURN SCREEN TO
{PROXY} AND ASK HIM/HER TO RECORD HIS/HER MEC EXAM AND MEC INTERVIEW RECORDING CHOICE BELOW.
I have read the Examination Consent Brochure and Health Measurements List. I agree to allow SP to take part in the survey.
YES
NO
I agree to have SP’s interview about current health status, diet, and health behaviors recorded for quality control.
YES
NO
REVIEW SELECTIONS AND ASK RESPONDENT TO SIGN.
LANGUAGE: ENGLISH OMB# 0920-0950
YES I agree to allow SP to take part in the survey.
YES I permit NHANES to record SP’s interview about current health status, diet, and health behaviors.
Specimen Storage
PROVIDE SPECIMEN STORAGE FORM AND REVIEW KEY POINTS.
HAND RESPONDENT THE CONSENT/ASSENT AND PARENTAL PERMISSION FOR SPECIMEN STORAGE AND CONTINUING STUDIES FORM IN THE LANGUAGE HE/SHE READS.
REVIEW KEY POINTS WITH RESPONDENT OR READ CONSENT FORM OUT LOUD.
ANSWER ANY RESPONDENT QUESTIONS.
DISPLAY IMAGE OF CONSENT FORM.
LANGUAGE: ENGLISH OMB# 0920-0950
TURN SCREEN TO {PROXY} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.
REVIEW STATEMENTS AND ALLOW RESPONDENT TO MAKE SELECTIONS.
LANGUAGE: ENGLISH OMB# 0920-0950
EXPLAIN SPECIMEN STORAGE FOR FUTURE HEALTH STUDIES CHECK BOXES. TURN SCREEN
TO {PROXY} AND ASK HIM/HER TO RECORD HIS/HER SPECIMEN STORAGE CHOICE BELOW.
I agree to allow SP’s blood and urine to be kept for future health studies, and I understand that I will not be contacted with the results from these studies.
YES
NO
REVIEW SELECTIONS AND ASK RESPONDENT TO SIGN.
LANGUAGE: ENGLISH OMB# 0920-0950
YES I permit NHANES to keep SP’s blood and urine for future health studies, and I
understand that I will not be contacted with the results from these studies.
Authorization for Transportation
PROVIDE AUTHORIZATION FOR TRANSPORTATION FORM AND REVIEW KEY POINTS.
HAND RESPONDENT THE AUTHORIZATION FOR TRANSPORTATION ARRANGEMENTS FOR MINOR FORM IN THE LANGUAGE HE/SHE READS.
REVIEW KEY POINTS WITH RESPONDENT OR READ THE FORM OUT LOUD.
ANSWER ANY RESPONDENT QUESTIONS.
DISPLAY IMAGE OF CONSENT FORM.
LANGUAGE: ENGLISH OMB# 0920-0950
TURN SCREEN TO {PROXY NAME} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.
REVIEW STATEMENTS AND ALLOW RESPONDENT TO MAKE SELECTIONS.
LANGUAGE: ENGLISH OMB# 0920-0950
EXPLAIN THE TRANSPORTATION AND ESCORT CHECK BOXES. TURN SCREEN TO {PROXY NAME} AND ASK HIM/HER TO RECORD HIS/HER CHOICES BY TOUCHING ONE TRANSPORTATION AND ONE ESCORT STATEMENT BELOW.
TRANSPORTATION (CHOOSE ONE): I consent to transportation of {SP} to and from the Mobile Exam Center (MEC)/Field Office…
by members of the CDC health survey staff
in a taxi arranged and paid for by the CDC health survey
Parent/Guardian will arrange transportation, to and from the MEC/Field Office, for {SP}
ESCORT (CHOOSE ONE): I understand that children birth to 15 years old must come to the MEC accompanied by someone aged 18 and over.
Mother will accompany
Father will accompany
Other person 18 and over will accompany
Will come alone
If “Other person 18 and over will accompany” is selected, the respondent can select the adult from the household roster. If the adult is someone living outside the household, the respondent will be asked to provide the adult’s first and last name.
If the SP is 15 years old or younger, the option “Will come alone” would not be available.
REVIEW SELECTIONS AND ASK RESPONDENT TO SIGN.
LANGUAGE: ENGLISH OMB# 0920-0950
Parent/Guardian will arrange transportation, to and from the
Mobile Exam Center/Field Office, for {SP}.
Mother will accompany {SP} to the MEC.
Transition to minor SP as respondent
Is {SP} present and available to sign?
YES
NO. COME BACK LATER TO COLLECT MINOR’S SIGNATURES
NO. COLLECT MINOR’S SIGNATURES AT MEC
Is {SP} able to give assent and sign forms?
YES
NO. SP HAS COGNITIVE PROBLEMS
NO. SP HAS PHYSICAL PROBLEMS
If the SP cannot give assent and sign due to a cognitive or physical problem, the minor’s parent/guardian may sign for the child.
MEC Consent/Assent
PROVIDE MEC CONSENT BROCHURE AND REVIEW PACKET.
[Let’s take a look at a brochure as I explain the exam process to you.
HAND SP THE EXAMINATION CONSENT BROCHURE IN THE LANGUAGE HE/SHE READS.
REVIEW KEY POINTS FROM BROCHURE AND HEALTH MEASUREMENTS LIST, OR READ FORMS OUT LOUD AS NECESSARY.
REVIEW MEC DIAGRAM AND LAB TESTS ON BLOOD FLYERS AS NECESSARY.
REVIEW KEY POINTS FROM THE CONSENT/ASSENT AND PARENTAL PERMISSION FOR EXAM AT MEC IN THE LANGUAGE HE/SHE READS, OR READ FORM OUT LOUD.
ANSWER ANY RESPONDENT QUESTIONS.]
DISPLAY IMAGE OF CONSENT FORM.
LANGUAGE: ENGLISH OMB# 0920-0950
TURN SCREEN TO {SP} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.
REVIEW STATEMENTS AND ALLOW RESPONDENT TO MAKE SELECTIONS.
LANGUAGE: ENGLISH OMB# 0920-0950
EXPLAIN THE MEC EXAM AND MEC INTERVIEW RECORDING STATEMENTS. TURN SCREEN TO
{SP} AND ASK HIM/HER TO RECORD HIS/HER MEC EXAM AND MEC INTERVIEW RECORDING CHOICE BELOW.
I have read the Examination Consent Brochure and Health Measurements List. I agree to take part in the survey.
YES
NO
REVIEW SELECTIONS AND ASK RESPONDENT TO SIGN.
LANGUAGE: ENGLISH OMB# 0920-0950
YES I agree to take part in the survey.
PARENT/GUARDIAN agreed to allow NHANES to record my interview about current health status, diet, and health behaviors.
Specimen Storage
PROVIDE SPECIMEN STORAGE FORM AND REVIEW KEY POINTS.
[HAND SP THE CONSENT/ASSENT AND PARENTAL PERMISSION FOR SPECIMEN STORAGE AND CONTINUING STUDIES FORM IN THE LANGUAGE HE/SHE READS.
REVIEW KEY POINTS WITH SP OR READ CONSENT FORM OUT LOUD.
ANSWER ANY RESPONDENT QUESTIONS.]
DISPLAY IMAGE OF CONSENT FORM.
LANGUAGE: ENGLISH OMB# 0920-0950
TURN SCREEN TO {SP} AND EXPLAIN THAT YOU ARE REVIEWING THE SAME FORM HARDCOPY AND ELECTRONICALLY.
REVIEW STATEMENTS AND ALLOW RESPONDENT TO MAKE SELECTIONS.
LANGUAGE: ENGLISH OMB# 0920-0950
EXPLAIN SPECIMEN STORAGE FOR FUTURE HEALTH STUDIES CHECK BOXES. TURN SCREEN
TO {SP} AND ASK HIM/HER TO RECORD HIS/HER SPECIMEN STORAGE CHOICE BELOW.
My blood and urine to be kept for future health studies, and I understand that I will not be contacted with the results from these studies.
YES
NO
REVIEW SELECTIONS AND ASK RESPONDENT TO SIGN.
LANGUAGE: ENGLISH OMB# 0920-0950
YES I permit NHANES to keep my blood and urine for future health studies, and I
understand that I will not be contacted with the results from these studies.
PARENT/GUARDIAN agreed to allow NHANES to keep my blood and urine for future health studies.
DISPLAY SUMMARY OF RESPONDENT’S SELECTIONS. BECAUSE CONSENT WAS GIVEN ELECTRONICALLY, THE PROGRAM WILL FILL THE DROP-DOWN LISTS.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Myah Scott |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |