Home Interview Consent Form

ATTACHMENT 11a National Health and Nutrition Examination Survey

Home Interview Consent

Print name of person questioned_________________________________________________________

First Middle Last

Welcome to the National Health and Nutrition Examination Survey (NHANES). You have been selected to be part of this study which includes an interview and a health exam.  This study is sponsored by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. The information collected in this interview will be extremely valuable in understanding the health and nutrition of people in the United States.

Taking part in this interview is voluntary.  You may choose to skip any question you don’t wish to answer or end the interview at any time without penalty.  We are required by Federal law to develop and follow strict procedures to protect the confidentiality of your information and use your answers only for statistical purposes.  (Please refer to the laws shown on the back of the consent form.) On average, the interview will take less than 30 minutes.  As a thank you for your time and effort, you will receive a $25 debit card for completing the interview.

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.

______________________________________________________________________________

Witness (if required) Date

Name of staff member present when this form was signed:

______________________________________________________________________________

We can do additional health studies by linking the interview and exam data of everyone

listed below under “SP NAME” to vital statistics, health, nutrition, and

other related records. May we try to link these survey records with other records? (Please refer to the linkage information section on the back of the consent form.)

Yes No N/A

______________________________________________________________________________

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) 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.

Data linkage information:

By matching NHANES data with other health-related records, researchers can study health conditions like heart attacks and diabetes in depth. They can also better understand health care use and health care costs for all Americans. These findings will help doctors assist patients in making smart choices.

Do you have more questions about the survey?

You can make a toll-free call to the Chief Medical Officer at 1-800-452-6115, Monday-Friday, 7:30 AM-4:30 PM EST. If you have questions about your rights about being in the survey, call the 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.