Parental Permission Form and Fact Sheet for the Validation Study

High School Student Dietary Behavior Validation Study

Attachment J6

Parental Permission Form and Fact Sheet for the Validation Study

Parental Permission Form and Fact Sheet

Our school is taking part in the High School Student Dietary Behaviors Validation Study. This research project is sponsored by the Centers for Disease Control and Prevention (CDC).

Students will be asked to fill out a survey that takes about 10 minutes to complete. This survey will ask about how often 9th-12th grade students consume fruits, vegetables, and energy drinks. Students will also be invited to complete an interview about the foods and beverages they eat and drink. The survey and interview will be done in school during school hours.

Doing the digital survey and being interviewed about the foods and beverages they consume will cause little or no risk to your child. The study has been designed to protect your child's privacy. No school or student will ever be mentioned by name in a report of the results. Your child will get no benefit right away from taking part in the study, but the results of this study will help your child and other children in the future. We would like all selected students to take part in the study, but the study 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 study at any point without penalty. If you would like to see the survey, a copy is available in the school office.

State and local school officials and Solutions IRB have approved the study. You or your child may have questions about your child’s rights as a participant in this research study. If so, please call the CDC Human Research Protections Office at (800) 584-8814. Please leave a brief message with your name and phone number. Say that you are calling about CDC protocol #XXXX. We will return your call as soon as possible.

Please see the other side of this form for more facts about the study. If your child's teacher or principal cannot answer your questions about the study, call CONTACT INFO TBD.

Please read the section below. If you do not want your child to take part in the survey, check the box, sign and date the form and return the form to the school within 3 days. Signing and returning this form will dismiss your child from taking the survey. If you have no objection to your child taking part in the survey, you should do nothing with this form. Thank you.

Child's name: ______________________________________ Grade: ______________

I have read this form and know what the study is about.

[ ] My child may not take part in this survey.

Parent's signature: _________________________________ Date:_________________

P hone number: ___________________________________

This study is done under the authority of the Public Health Service Act (42 USC 241).

Study Fact Sheet

Q. Why is the study being done?

A. The Centers for Disease Control and Prevention (CDC) will use the study results to help measure the fruit, vegetable, and energy drink consumption of high school students.

Q. Are sensitive questions asked?

A. In general, questions about nutrition are considered to be minimally sensitive.

Q. Will student names be used or linked to the surveys?

A. The study has been designed to protect your child’s privacy. Students will complete the survey digitally using a unique identifying number. The connection between the student’s name and unique ID will not be retained or transmitted to CDC.

Q. Do students take the survey more than once to see how their consumption changes?

A. No. Students will not be asked to participate in the survey more than once.

Q. What does the interview involve?

A. Students will be asked about all the foods and beverages they consumed the day before the interview. They will be asked the portion size of what they ate and drank and the time of day that they ate and drank each item. The interview will take about 20-30 minutes to complete.

Q. How was my child picked to be in the study?

A. About 800 students from approximately 12 schools in the United States were picked to take part. One class (about 25 students) in each grade 9 through 12 was picked randomly to take part in each school.

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

A. 10 minutes are needed to fill out the written survey, which has 10 questions.

Q. Can I see the questions my student will be asked?
A. Yes, a copy of the survey is at your student’s school.

Q. Does the study have national support?

A. Yes. The High School Student Dietary Behaviors Validation Study is being conducted to strengthen the Youth Risk Behavior Survey, which as the support of the following organizations: the American Academy of Pediatrics, the American Association for Health Education, the American Association of School Administrators, the American Cancer Society, the American Medical Association, the Association of State and Territorial Chronic Disease Directors, the Association of State and Territorial Health Officials, the Council of Chief State School Officers, the National Association of Chronic Disease Directors, the National Association of State Boards of Education, the National Education Association, the National PTA, and the National School Boards Association.