Consent

Form Approved OMB No. 0990-XXXX Exp. Date XX/XX/2018

U.S. Department of Health and Human Services

President’s Council on Sports, Fitness & Nutrition

Consent to Participate In

Evaluation of I Can Do It!

The President’s Council on Sports, Fitness & Nutrition is sponsoring a research study. Vantage Human Resource Services, Inc. and Dr. Jennifer Shultz, PhD are under contract with PCSFN to conduct the study. The purpose of the study is to evaluate how this inclusive health promotion program might influence a participant’s physical activity and healthy eating. You are being asked to participate in this study because you are a participant (a mentee, parent of a mentee, or a mentor) of I Can Do It, You Can Do It!.

Your participation will involve completing a mentee/mentor survey(s). If you are a mentee (or parent of a mentee), you will complete two surveys: a paper-based pre-assessment at the beginning of the program and a paper-based post-assessment at the end of the program. Each assessment will take about 25 minutes to complete.

If you are a mentor, you will complete an online survey at the end of the 8 week program. This survey will take about 10 minutes to complete.

Your involvement in the study is voluntary, and you may choose not to participate. The forms and surveys include questions about your physical activity and healthy eating behaviors, basic demographics, and opinions about participation in the program. You can refuse to answer any of the questions at any time.

There are no known risks in this study, but some individuals may experience discomfort when answering questions. All data will be kept for 1 year in a locked file in Dr. Shultz’s office and then destroyed.

Each survey will be coded with a unique study number. No names or other personal identifiers will appear on the survey. All completed surveys will be kept private to the extent permitted by law, and only research staff and the President’s Council on Sports, Fitness & Nutrition (PCSFN) will have access to research data.

The findings from this project will provide information on improving I Can Do It, You Can Do It!. If published, results will be presented in summary form only. You can access further information about the study or the research findings via the PCSFN website: www.fitness.gov.

If you have any questions about this research project, please feel free to call Jennifer Shultz at (410) 835-8684. If you have questions regarding your legal rights as a research subject, you may call the Salus Institutional Review Board at (xxx) xxx-xxxx.

By completing any of the forms or surveys, you will be agreeing to participate in the above described research study. Thank you for your consideration.

Sincerely,

Jennifer Shultz

Dr. Jennifer Shultz

Vantage Human Resource Services, Inc.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average XX minutes per response. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.