MEC Adult Parental_Child_Consent_Assent Form

ATTACHMENT 11f

NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY

OMB # 0920-0950

CONSENT/ASSENT AND PARENTAL PERMISSION FOR EXAMINATION AT THE MOBILE EXAMINATION CENTER

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)

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.

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 participant Date

Signature of parent or guardian Date

FOR PARENT OR GUARDIAN OF SURVEY

PARTICIPANT 12-17 YEARS (check the box):

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

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

SURVEY PARTICIPANT WHO IS 7-11 YEARS:

Your parents say you can take part in this special survey. You have just read about the survey in this booklet.

If you want to take part in the survey, write your name below.

current health status, diet, and health behaviors recorded for _{quality control. } Signature of participant 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:

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) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)).  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.

2021

SP ID