Informed parental consent

Attachment D.1: PARENT/GUARDIAN PERMISSIOM FORM – COGNITIVE INTERVIEWING

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx)

PERMISSION FORM FOR PARENT/GUARDIAN OF DEPENDENT RESPONDENT

THIS PERMISSION FORM WILL BE READ TO THE PARENT/GUARDIAN

INTRODUCTION

Hello, my name is _____. I am a survey interviewer from NORC at the University of Chicago for a research study supported by the [BALTIMORE CITY HEALTH DEPARTMENT/GARRETT COUNTY HEALTH DEPARTMENT] in partnership with the U.S. Centers for Disease control and Prevention. We are conducting interviews with young people to improve the way information is collected in surveys.

We are interviewing youth who are between 13 and 24 years old. We are doing this interview with them to help us improve the way we ask young people about their health, educational, and life experiences. This study is intended to suggest ways to improve the procedures NORC and the CDC uses to collect survey data. We are doing this study to learn how to improve the ways we collect information using surveys. The survey asks a lot of different types of questions. I will not ask your child to answer the questions – what we want to know is how well people their child’s age would understand the questions. We will ask your child things like whether they understand what the questions are asking, and whether there are any words, terms, or phrases that are confusing to them?

During this research your child may be audio and/or videotaped, or may be observed. If you do not wish for your child to be taped, they still may participate in this research. We estimate it will take your child an average of 60 minutes to participate in this research.

There is little or no risk to your child, you or your family for participating in this survey. There are no consequences for not participating. Youth respondents will receive a $50 gift card as a small token of appreciation for participating in the interview.

I want to assure you that all of their answers will be kept strictly confidential, and their name and address will not be connected with any of their responses. Your child’s participation in this research project is voluntary, and you or they have the right to stop at any time.

Do you have any questions?

For any further concerns about your child’s rights and your rights in this survey or the procedures I am following, you may contact: [XXXXXXXXXXXXXXX FROM BALTIMORE CITY HEALTH DEPARTMENT AT (404)-XXX-XXXX/GARRETT COUNTY HEALTH DEPARTMENT AT (XXX)-XXX-XXXX] or XXXXXXXXXX from NORC at the University of Chicago at (301) XXX-XXXX, who are prepared to address your concerns or refer you to someone who can. Please feel free to write down this information for future reference.

Do you give your permission for your child to participate in this study?

Does not GIVE PERMISSION FOR CHILD TO PARTICIPATE

GIVES PERMISSION FOR CHILD TO PARTICIPATE

Name of Interviewer Obtaining Verbal Permission:____________________________________

Date:___________________________________________