Consent Adult Proxy - English

Attachment F-3. Consent Adult Proxy – English

ASK IF PARENT/GUARDIAN OF children in household

CPROXY. You have been randomly chosen to participate in this important study. The Centers for Disease Control and Prevention (CDC) is sponsoring this telephone study of up to 10,000 people in the United States to find out about their experiences with head injuries in the past 12 months.

We will also ask you about the [IF NUMC=1 READ “child’s” / IF NUMC >1 READ “children’s”] experiences with head injuries in the past 12 months. Even if you or the [IF NUMC=1 READ “child has” / IF NUMC>1 READ “children have”] not had an injury in the past 12 months, you can still participate in this important study.

The data we are collecting are very important, and will be used to guide national policies. The majority of respondents will complete the survey in less than 20 minutes.

There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your information private, your name will never be connected to your answers. CDC will keep the information that you provide about you and the children private and secure to the extent permitted by the law. You can skip any question or stop the survey at any time. If you have questions or concerns about participating in the study, you may contact ICF, the independent health research company hired to conduct this survey. They can be reached toll-free at -1-844-604-4399. If you have any questions about your rights as a research participant, please contact Sophia Zanakos at 301-572-0239. This call may be monitored for quality assurance purposes.

May we begin?

1. YES [SKIP TO TRANS1]

2. NO [SCHEDULE CALLBACK]