CONSENT/ASSENT AND PARENTAL PERMISSION FOR EXAMINATION AT THE MOBILE EXAMINATION CENTER
Print name of participant
First Middle Last
For the Parent or Guardian of the Survey Participant who is a minor (unless the participant is an emancipated minor)
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
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 .
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.
SP ID
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Chiappa, Michele (CDC/DDPHSS/NCHS/DHNES) (CTR) |
File Modified | 0000-00-00 |
File Created | 2022-08-17 |