Home Interview Consent

#1 OMB # 0920-0950

National Health and Nutrition Examination Survey

Home Interview Consent

Attachment 2d

Print name of person questioned ____________________ ___________________ ____________________

First Middle Last

You have been chosen to take part in the National Health and Nutrition Examination Survey (NHANES), conducted by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention (CDC). This research tells us about the health and nutrition of people in the United States. It combines an interview with a health exam. Our interviewer will ask questions about you and your family. Some questions are about your work and general health. Others are about health problems and other health topics. Health research using NHANES can be enhanced by combining your survey records with other data sources. The data gathered are used to link your answers to vital statistics, health, nutrition, and other related records. The questions today will take about one hour. We may contact you to check the work of your interviewer. We may contact you again for further studies.

Data gathered in this survey are used to study many health issues. We are required by law (read box below) to use your information for statistical research only and to keep it confidential.

You may take part in this survey or not. The choice is yours. You will not lose any benefits if you say no. If you choose to take part, you don’t have to answer every question and you can stop the interview at any time.

We can do additional health research by linking the interview and exam data of everyone listed under “SP NAME” in the gray box below to vital statistics, health, nutrition, and other related records. May we try to link these survey records with other records?

 Yes  No  N/A

Do you have more questions about the survey? You can make a toll-free call to the Senior Medical Officer at 1-800-452-6115, Monday-Friday, 7:30 AM-4:30 PM ET. If you have questions about your rights about being in the survey, call the Research Ethics Review Board at the National Center for Health Statistics, toll free, at 1-800-223-8118. Please leave a brief message with your name and phone number. Say that you are calling about Protocol # 2018-01. Your call will be returned as soon as possible.

SIGNATURE OF PERSON ANSWERING QUESTIONS:

I have read the information above. I agree to proceed with the interview.

_______________________________________________________________ ___________________

Date

IF PERSON ABOVE IS 16 OR 17 YEARS OLD, A PARENT/GUARDIAN MUST ALSO SIGN BELOW:

(Unless participant is an emancipated minor )

_______________________________________________________________ ___________________

Signature of parent/guardian Date

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

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

HOUSEHOLD ID ___ ___ ___ ___ ___ ___ ___ ___ ___ FAMILY # ___ ___

Which questionnaire(s) did person respond to? FAMILY  SP  (IF CHECKED, PRINT BELOW)

SP NAME SP ID SP NAME SP ID

__________________________________________ __ __ __ __ __ __ _____________________________________ __ __ __ __ __ __

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.

01/18