Consent-Assent and Parental Permission Form

OMB # 0920-0950

National Health and Nutrition Examination Survey

Consent/Assent and Parental Permission for Examination at the Mobile Examination Center

Attachment 3b

Print name of participant ____________________ _________________ _____________

First Middle Last

PARENT OR GUARDIAN OF SURVEY PARTICIPANT WHO IS UNDER 18 YEARS OLD:

For the Parent or Guardian of the Survey Participant who is a minor (unless the participant is an emancipated minor)

I have read the Examination Brochure and the Health Measurements List, which explain the nature and purpose of the survey. I freely choose to let my child take part in the survey.

________________________________ ______

Signature of parent/guardian Date

FOR PARENT OR GUARDIAN OF SURVEY PARTICIPANT 12-17 YEARS:

 I agree to have my child’s interview about his/her current health status, diet, and health behaviors recorded for quality control.

 I do not agree to have my child’s interview about his/her current health status, diet, and health behaviors recorded for quality control.

SURVEY PARTICIPANT WHO IS 12 YEARS OLD OR OLDER:

I have read the Examination Brochure and the Health Measurements List, which explain the nature and purpose of the survey. I freely choose to take part in the survey.

________________________________ _____

Signature of participant Date

If you are 18 and older and do not want a written report of your exam results, check here 

I observed the interviewer read this form to the person named above and he/she agreed to participate by signing or marking this form.

__________________________________________________________ _________________

Witness (if required) Date

Assurance of Confidentiality: We take your privacy very seriously.  All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.  NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.  In addition, NCHS complies with the Federal Cybersecurity Act of 2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the government.

02/2017

Name of staff member present when this form was signed: _______________________________________

___ ___ ___ ___ ___ ___

SP ID