Consent/Assent Forms - sample

Attachment 8 – Sample Consent and Assent Forms for Poison Center Collaborations for Public Health Emergencies

Date: ____/____/______ Name of interviewer: _______________________

Poison center: _____________________________

State call originated from: ____________________

NPDS Case ID No. ____________________

Note: At least three attempts should be made to contact a consenting adult who was either the person who placed the original call to the PC or an individual adult who was present at the time of the original call to the PC concerning the [type of exposure].

Introduction Script and Consent (for adults 18 and older)

The Centers for Disease Control and Prevention and the [poison center] is doing this follow-up survey to find out about the health of people who may have been affected by the [description of the public health emergency] on [date of emergency]. CDC is allowed to ask these questions under the Public Health Service Act Section 301 [241].

This interview will take approximately 40 minutes to complete. It should take place in a private setting. We will ask you questions about:

- where you were and what you were doing when the [description of the public health emergency] happened.

- health effects during the [public health emergency],

- health messages you received during the [public health emergency]

There are no known risks from taking part in the survey. Some of the questions are personal and ask about sickness. There is no direct benefit from being in the survey. However, what you tell us will help us better learn about how this public health emergency is affecting people's health. We may also be able to use what we learn to help your community. They may also learn how to better prepare for future disasters.

We are asking you to take part in this survey because you had called a poison center regarding an exposure related to the public health emergency. You can choose if you want to be interviewed. You can stop the interview at any time. You can also refuse to answer any question. If you refuse, it will not affect any government benefits that you receive.

Names of people who take part and other identifying information will not be given to CDC or used in any report. Everything we learn will be kept private to the fullest extent of the law. Only project team members will be allowed to view this information.

If you have any questions about the study investigation, you may call ______________ from the ______________ poison center or [CDC representative] from the Centers for Disease Control and Prevention [phone number].

Participant name: ________________________________

Are you willing to take part at this time?

Yes

No Thank the respondent and end the call

***If Yes, please read the following to the consenting adult: ***

I have been read this consent form and I understand it. I have been given a chance to ask questions and I feel that my questions have been answered. I know that being in this investigation is my choice. I agree to be in this investigation.

Date __/__/____

Name of consenting adult: ______________________________________________

Name of poison center official taking consent:________________________________________

Sample Assent and Parental Permission (15 and <18 years)

Date: ____/____/______ Name of interviewer: _______________________

Poison center: _____________________________

State call originated from: ____________________

NPDS Case ID No. ____________________

Introduction Script

The Centers for Disease Control and Prevention and the [poison center] is doing this survey to find out about the health of people who may have been affected by the [description of the public health emergency] on [date of emergency]. CDC is allowed to ask these questions under the Public Health Service Act Section 301 [241].

This interview will take approximately 40 minutes to complete. It should take place in a private setting. We will ask you questions about:

- where you were and what you were doing when the [description of the public health emergency] happened.

- health effects during the [public health emergency],

- health messages you received during the [public health emergency]

There are no known risks from taking part in the survey. Some of the questions are personal and ask about sickness. There is no direct benefit from being in the survey. However, what you tell us will help us better learn about how this public health emergency is affecting people's health. We may also be able to use what we learn to help your community. They may also learn how to better prepare for future disasters.

We are asking you to take part in this survey because you called a poison center regarding <event name> an exposure related to the public health emergency. You can choose if you want to be interviewed. You can stop the interview at any time. You can also refuse to answer any question. If you refuse, it will not affect any government benefits that you receive.

Names of people who take part and other identifying information will not be given to CDC or used in any report. Everything we learn will be kept private to the fullest extent of the law. Only project team members will be allowed to view this information.

If you have any questions about the study investigation, you may call ______________ from the ______________ poison center or [CDC representative] from the Centers for Disease Control and Prevention [phone number].

If participant is a minor aged 15 and <18 yrs.:

Name of parent/guardian: ________________________________

If participant is a minor: Has your parent or legal guardian agreed for you to participate?

Yes

No Thank the respondent and end the call

I verify that I have explained this survey to you. You have agreed to participate.

If participant is a minor: Your parent or legal guardian has also agreed for you to participate in this interview.

***If Yes, please read the following to the consenting minor:***

I have been read this consent form and I understand it. I have been given a chance to ask questions and I feel that my questions have been answered. I know that being in this investigation is my choice. I agree to be in this investigation.

Date __/__/____

Name of consenting minor: ______________________________________________

Name of poison center official taking consent:________________________________________

***If yes, you must also gain parent/legal guardian assent before beginning the interview. Read the statement below to the parent/legal guardian to confirm their assent.***

As the parent/legal guardian for the above named, I give my permission for him/her to take part in this interview.

Date __/__/____

Name of assenting parent/legal guardian: ____________________________________________

Name of poison center official taking assent:________________________________________

Sample Consent Form for Parents or Guardians of Children (< 15 yrs.)

Date: ____/____/______ Name of interviewer: _______________________

Poison center: _____________________________

State call originated from: ____________________

NPDS Case ID No. ____________________

Introduction Script

The Centers for Disease Control and Prevention and the [poison center] is doing this follow-up survey to find out about the health of people who may have been affected by the [description of the public health emergency] on [date of emergency]. CDC is allowed to ask these questions under the Public Health Service Act Section 301 [241].

This interview will take approximately 40 minutes to complete. It should take place in a private setting. We will ask you questions about:

- where your child was and what he/she was doing when the [description of the public health emergency] happened.

- health effects during the [public health emergency],

- health messages you received during the [public health emergency]

There are no known risks from taking part in the survey. Some of the questions are personal and ask about sickness. There is no direct benefit from being in the survey. However, what you tell us will help us better learn about how this public health emergency is affecting people's health. We may also be able to use what we learn to help your community. They may also learn how to better prepare for future disasters.

We are asking you to take part in this survey because you had called a poison center regarding an exposure in which your child was involved related to a public health emergency. You can choose if you want to be interviewed. You can stop the interview at any time. You can also refuse to answer any question. If you refuse, it will not affect any government benefits that you receive.

Names of people who take part and other identifying information will not be given to CDC or used in any report. Everything we learn will be kept private to the fullest extent of the law. Only project team members will be allowed to view this information.

If you have any questions about the study investigation, you may call ______________ from the ______________ poison center or [CDC representative] from the Centers for Disease Control and Prevention [phone number].

Are you willing to take part at this time?

Yes

No Thank the respondent and end the call

***If Yes, please read the following to the consenting adult: ***

I have been read this consent form and I understand it. I have been given a chance to ask questions and I feel that my questions have been answered. I know that being in this investigation is my choice. I agree to be in this investigation.

Date __/__/____

Child’s name: ________________________________

Name of consenting adult or guardian: ______________________________________________

Name of poison center official taking consent: ________________________________________