Cognitive Testing Parental Consent Form

Attachment Q4: Parent Consent Form

Parental permission for minor child to be in a cognitive interview on understanding use of tobacco among youth

Introduction:

The Centers for Disease Control and Prevention (CDC) is sponsoring a project to help ensure that we ask survey questions about tobacco use in a manner that youth can understand. Your child has been asked to participate in this project. NORC at the University of Chicago (NORC) will be doing the interviews on behalf of CDC.

What is the purpose of this project?

The purpose of this project is to test questions that will be used in future surveys of youth about tobacco use. The questions focus on electronic cigarettes (e-cigarettes) and other types of tobacco products. Your child’s feedback will help us ensure that these questions are understandable to other youth who will complete the survey in the future.

How long will you need my child to participate?

The interviews will take about 60 minutes.

What do you want my child to do if I give my permission for him/her to be in this project?

If you agree to let your child participate in the project, your child will be asked to respond to questions in his or her own words to help us understand how he or she thinks and talks about e-cigarettes. Questions focus on topics like types of e-cigarettes, use of e-cigarettes in schools, nicotine, flavors, social media, and experiences at home and at school. We will explain the procedures to your child and ensure he/she is comfortable before we begin. We will audio record the interview to help us create an accurate set of notes to review later, and some of the people working on the project may watch the interview through a one-way mirror or may listen through the phone to take notes. We will destroy the recordings once analysis is complete.

Are there any risks to my child if he/she is in this project?

There is no known physical risk to your child from being in this project. There is a small chance that your child might feel uncomfortable by the things that are talked about during the interview. Some of the questions may be sensitive in nature because they ask about activities that may be illegal when underage (like e-cigarette use). All information your child provides will be kept private to the extent required by law. Participation is voluntary and your child can choose not to answer any of the questions that make him/her uncomfortable. Your child can say that he or she does not want to talk about any topic for any reason. Your child also can stop participating in the interview at any time. Your child will be reminded at the end of the session that there are no safe tobacco products, including e-cigarettes, and provided educational materials about the harms of tobacco use.

Are there any benefits to my child from being in this project?

There are no direct benefits to you or your child for participating in this project. However, the results from this project will help CDC better understand how teens think and talk about tobacco products, including e-cigarettes.

How will the information I give you about my child and the information my child gives you be kept private?

We will not use your child’s name in any interview notes and his/her name will not be linked to any of his/her responses. All information that we collect during the interview will be treated in a secure manner. We will destroy the recording and the interview notes at the end of the project. Only certain project staff who have been trained on the project will be able to access any of this information before it is destroyed. Every effort will be taken to ensure the information your child shares is kept private but, there is still a small chance that your child’s privacy could be broken.

Who should I call if I have questions about this project?

You may ask questions or express concerns about the project at any time before, during or after the project. You may contact Ashani Johnson-Turbes, Principal Research Scientist at NORC, at 404-240-8411or [email protected].

Who should I call if I have a question about my child’s rights as a volunteer?

NORC is conducting this project on behalf of CDC. If you have any questions about your rights or treatment by the interviewers, please contact NORC’s Institutional Review Board at 1-866-309-0542. Leave a message with your name and phone number and someone will contact you.

Does my child have to participate in this project?

No. Your consent and your child’s participation in this project are completely voluntary. Your child may end his/her participation or refuse to answer any questions at any time for any reason. You may withdraw your consent and stop your child’s participation at any time before the end of the interview. If you decline to participate in this project, you and your child will not be affected in any way. There will be no consequences, and your child will still be paid. Additionally, if at any time the interviewer feels it is not in your child’s best interest to continue, he/she will stop the interview.

Where will the interview take place?

The interview will take place at [to be determined].

Compensation:

Your child will receive $40 to cover time and transportation costs.

Do you provide your permission?

[YES/NO]

Verbal Parental permission recorded by ________________________ on ___/ ____/ 20___