Parental Permission Form and Fact Sheet Passive - English

This form only needs to be signed and returned if you do NOT want your child to participate.
P
PARENTAL PERMISSION FORM
Our school is taking part in the 2021 National Youth Tobacco Survey (NYTS). This research project
is sponsored by the Centers for Disease Control and Prevention (CDC). Students in grades 6 through
12 will be asked to complete a survey about their tobacco and nicotine related beliefs, attitudes and
behaviors, intent to use, and exposure to influences that promote or discourage tobacco and nicotine
use.
Students will be asked to use a tablet or Internet-connected device to fill out a survey that takes about
25 minutes to complete.
Doing this survey will pose no physical risk to your child. The survey has been designed to protect
your child’s privacy. Students will not enter their names in the survey. Also, no school or student will
ever be mentioned by name in a report of the results. Your child will get no immediate benefit from
taking part in the survey; however, the results of this survey will help your child and other children in
the future. We would like all selected students to take part in the survey, but the survey is voluntary.
No action will be taken against the school, you, or your child, if your child does not take part. Students
can skip any questions that they do not wish to answer. In addition, students may stop participating in
the survey at any point without penalty. If you would like to see the survey, a copy is available in the
school office. Your child will be asked specifically about electronic cigarettes, cigarettes, cigars,
smokeless tobacco, hookahs, pipe tobacco, and bidis.
State and local school officials and a review board at CDC have approved the survey. You or your
child may have questions about your child’s rights as a participant in this research project. If so, please
call the CDC Human Research Protections Office at 1-800-584-8814. Please leave a brief message
with your name and phone number. Say that you are calling about CDC protocol #4118. We will
return your call as soon as possible.
Please read the section below and check the box only if you do not want your child to take part in the
survey. If you check the box “no,” sign the form and return it to the school within 3 days. Please see
the other side of this form for more facts about the survey. If your child's teacher or principal cannot
answer your questions about the survey, please call Alice Roberts, Project Director, toll-free at 1-800675-9727. Thank you.
_________________________________________________________________________________
Child’s name: _________________________________________________

Grade: ________

I have read this form and know what the survey is about.
NO, my child may not take part in this survey.
Parent or guardian’s signature: ____________________________________

Date: __________

Please see the other side of this form for more facts about the survey.

SURVEY FACT SHEET
Q.

Why is the 2021 NYTS being done?

A.

The purpose of the NYTS is to gather nationally representative data for students in grades 6 through 12
for the following tobacco and nicotine related topics: (1) prevalence of use (electronic cigarettes,
cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis), (2) knowledge and attitudes,
(3) media and advertising, (4) minors’ access and enforcement, (5) school curriculum, (6) secondhand
smoke exposure, and (7) cessation.

Q.

Are sensitive questions asked?

A.

Students will be asked specifically about electronic cigarettes, cigarettes, cigars, smokeless tobacco,
hookahs, pipe tobacco, and bidis. Some students may consider some questions sensitive, especially
those asking about content with which they are not familiar, such as pipes, snus, or dissolvable tobacco.
The survey relates to students’ attitudes, behaviors, and knowledge about tobacco and nicotine use,
intent to use, exposure to tobacco and nicotine use, and exposure to tobacco and nicotine
marketing/advertising.

Q.

Will student names be used or linked to the surveys?

A.

No. The survey has been designed to protect your child’s privacy. Teachers are not involved directly.
Specially trained field staff will administer the survey in each selected school. Students do not enter
their name in the survey.

Q.

Do students take the survey more than once to see how their behaviors change?

A.

No. Each year a new sample of states, schools, and students is selected. Students who take part one
year cannot be tracked because their names are not on the survey.

Q.

How was my child selected to be in the survey?

A.

About 24,000 students from approximately 365 schools across the country were selected to take part.
One or two classes (about 25 to 50 students) in each grade 6 through 12 were picked randomly to take
part in each school.

Q.

How long does it take to fill out the survey? Does the survey include a physical test?

A.

One class period is needed to fill out the survey. The survey does not include a physical test or exam.

Q.

Can I see the questions my child will be asked?

A.

Yes, a copy of the survey is at your child’s school.