Attachment 4a-4f- Informed Consent 4.28.23

Attachment 4a-4f- Informed Consent 4.28.23.docx

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Attachment 4a-4f- Informed Consent 4.28.23

OMB: 0920-0222

Document [docx]

Download: docx | pdf

Attachment 4a – Parent/Guardian informed consent form for minors (in-person interviews)

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

Shape1 National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Informed Consent Form

Parent/Guardian Permission

One-on-one Interviews

Your child is being asked to take part in a research study. This consent form tells you about the study and what your child will be asked to do. You can choose to have your child take part in the study or not. If you permit your child to take part, you will need to read this entire form and sign it. Your child will also have an assent form to read and sign.

Purpose of the Research

Surveys are used to collect information on the health and wellbeing of Americans. The surveys help to develop programs to improve the health and health care of people living in the United States.

Before health surveys are conducted, the questions are tested with people of different backgrounds. It is important that the questions make sense, are easy to answer, and that everyone understands the questions the same way. The National Center for Health Statistics (NCHS) conducts these tests for the surveys it sponsors and for other survey programs. If you permit your child to take part in this test, we will ask your child to answer the survey questions. Then, we will ask your child to explain what they were thinking and how they came up with their answers.

The questions we are working on today are about your child’s childhood experiences that can be positive (such as feeling safe or supported by friends) or negative (such as experiencing abuse or bullying). The questions are being tested by NCHS on behalf of the National Center for Injury Prevention and Control (NCIPC). It is not necessary to have had these experiences to participate.

Your child’s interview will show us how to improve the questions for this survey. In the future, we may also study your child’s interview along with interviews from other projects. This type of study will teach us about the different kinds of problems young people have answering survey questions. The study will help us write better questions in the future.

Procedures

We ask that you complete a personal information sheet.

A member of the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) team, either a staff interviewer or a contracted interviewer from Research Support Services (RSS), will ask your child some survey questions. Then, the interviewer will ask your child to explain what they were thinking as they answered the questions. The interviewer will ask if there were any words that were confusing and if your child understood what was being asked. While the interview is going on, researchers from the CCQDER and RSS contractors who are working on the project may listen to the interview.

Your child may find that some of the questions we are testing are sensitive. He/she may choose not to answer any question for any reason. If he/she does not want to answer a question, he/she can say so, and we will move on to the next one. Your child may also stop the interview at any time. If you or your child experience emotional distress during or after the interview and need help, call or text #988, which connects to a crisis hotline offering free and confidential support.

If you have questions about how the project works, contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470 3311 Toledo Rd., Hyattsville, MD 20782.

Recordings

We would like to audio record your child’s interview. The recording allows us to more carefully study and improve the questions. At the bottom of this form, you will be asked if you are willing to have your child’s interview recorded. If you agree, your child may still ask to stop the recording at any time, and we will turn off the machine. If your child decides to stop recording, we will ask his/her assent to retain the portion already recorded. When the interview is finished, your child may listen to the recording. You will not be allowed to listen to the interview while it is being recorded or listen to the recording at a later time.

If you agree to record your child’s interview, we will keep it in a locked room either in a secure storage cabinet or on a password-secured computer that is not connected to the internet. Only researchers from the CCQDER and RSS contractors, working on the project will be allowed to listen to the recording in a secured room. When in use all recordings will be in the safe keeping of a staff person from the CCQDER. The recorded interview will be destroyed at the end of the project unless you agree to let us keep it longer.

You may decide at any time after the interview that you don’t want us to keep a recording of the interview. In this case, you may contact Ms. Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470, 3311 Toledo Rd., Hyattsville, MD 20782. When she receives your request, the recording of your interview will be immediately destroyed.

Privacy

We are required by law¹ to tell you what we will do with the recording. We must also tell you how we will protect your child’s privacy.

Audio recordings are stored in a locked room or secured by a password. All recordings are labeled by a code number, date, time, and project title. The recording is never labeled with your child’s name or other personal facts.

Materials with personal facts (such as names or addresses) are also stored in a locked room. Only CCQDER staff has access to this material.

Your child’s name or other personal facts that would identify you will not be used when we discuss or write about this study. People working on this project or those listening to the audio recording, however, may recognize your child’s voice.

If you have questions about National Center for Health Statistics privacy’ laws and practices, contact the NCHS Confidentiality Office by phone at 888-642-4159 or 301-458-4601, or by email at [email protected]

Benefits and Risks

There are no direct benefits to you or your child from taking part in this study.

The possible risks of taking part in this study are minimal. We will take all possible steps to protect your child’s privacy. Your child does not have to give us any information that he/she does not want to, and he/she can choose not to answer any question in the interview. He/she may also stop at any time and still receive the full $50.

Conducting an interview at a mutual location²

In order for your child to take part in the study today, we agreed to meet at a different location and not at the National Center for Health Statistics. Meeting at the different location is your choice. However, you are urged to choose a place that is private so that your child will feel comfortable answering the questions. We will protect any materials that contain your child’s personal information and transport them to the National Center for Health Statistics.

If you have any questions about this study, please call the office of 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 Project ID XX. [Note: Project ID will be inserted into the form once NCHS ERB approval has been received] Your call will be returned as soon as possible.

Please Read and Sign Below if You Agree

ÿ I freely choose to allow my child to take part in this research study.

I allow NCHS to audio record my child’s interview. I also allow NCHS to play my child’s audio recording to researchers from NCIPC, CCQDER and RSS, on-site at NCHS CCQDER.

ÿ Yes ÿ No

IF YES:

I allow NCHS to retain my child’s audio recording for future research on how people react to survey questions and how survey questions can be hard to understand or hard to answer. I also allow NCHS to play my child’s audio recording to internal NCHS CCQDER staff. I understand that the recording of my interview will be kept for as long as it is of interest to researchers (a minimum of two years).

ÿ Yes ÿ No

______________________________ __________________________ __________

Parent/Guardian Signature Print Name Date

¹This paragraph will be included in the consent form for those interviews conducted at the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER).

²Either video or audio will be selected.

³The Public Health Service Act provides us with the authority to do this research (42 U.S.C 242k). 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(d)) and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583). 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. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

⁴This paragraph will be included in the consent form for those interviews conducted offsite.

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑

Public reporting burden for this collection of information is estimated to average 60 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, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 01/31/2026

Attachment 4b - Informed assent form for minors (in-person)

D EPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

Shape2 National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Informed Assent Form

Young People

One-on-one Interviews

Your parent or guardian has given permission for you to take part in a research study. This assent form tells you about the study and what you will be asked to do. You can choose to take part in the study or not. If you choose to take part, you will need to read this entire form and sign it.

Purpose of the Research

One way the National Center for Health Statistics (NCHS) learns about health in this country is to ask people questions on surveys. Before the surveys are conducted, we try out the questions with people like you. There are no right or wrong answers to the questions. We want to make sure that the questions are easy to answer and that everyone understands them in the same way. If you agree to take part, we will try out the questions with you. We will first ask you to answer the questions and then ask you to explain what you were thinking.

The questions we are trying out today are about your childhood experiences that can be positive (such as feeling safe or supported by friends) or negative (such as experiencing abuse or bullying). It is not necessary to have had these experiences to participate. Your interview will help us to understand the different types of problems young people have answering the survey questions and will show us how to write better questions in the future.

NCHS is trying out the questions for the National Center for Injury Prevention and Control (NCIPC).

Procedures

We ask that you complete a personal information sheet.

If you have questions about how the project works, contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470 3311 Toledo Rd., Hyattsville, MD 20782.

Recordings

We would like to audio record your interview. The recording allows us to more carefully study and improve the survey questions. At the bottom of this form, you will be asked if you are willing to have the interview audio recorded. If you agree, you may still ask to stop the recording at any time, and we will turn off the machine. If you decide to stop recording, we will ask your assent to retain the portion already recorded. When the interview is finished, you may listen to the recording.

Privacy

We are required by law¹ to tell you what we will do with the recording. We must also tell you how we will protect your privacy.

Materials with personal facts (such as names or addresses) are also stored in a locked room. Only our staff have access to this material.

Your name or other personal facts that would identify you will not be used when we discuss or write about this study. People working on this project or those listening to the recording, however, may recognize your voice.

Benefits and Risks

There are no direct benefits to you from taking part in this study.

Conducting an interview at a mutual location²

In order for you to take part in the study today, we agreed to meet at this location. Meeting at this location is your choice. However, you are urged to choose a place that is private so that you will feel comfortable answering the questions. We will protect any materials that contain your personal information and transport them to the NCHS.

If you have any questions about this study, please call the office of 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 Project IDXX. [Note: Project ID will be inserted into the form once NCHS ERB approval has been received] Your call will be returned as soon as possible.

Please Read and Sign Below if You Agree

ÿ I freely choose to take part in this research study.

I allow NCHS to audio record my interview. I also allow NCHS to play my audio recording to researchers from CCQDER, RSS, and NCIPC, on-site at NCHS CCQDER.

ÿ Yes ÿ No

IF YES:

I allow NCHS to retain my audio recording for future research on how people react to survey questions and how survey questions can be hard to understand or hard to answer. I also allow NCHS to play my audio recording to internal NCHS CCQDER staff. I understand that the recording of my interview will be kept for as long as it is of interest to researchers (a minimum of two years).

ÿ Yes ÿ No

______________________________ __________________________ __________

Respondent Signature Print Name Date

¹This paragraph will be included in the consent form for those interviews conducted at the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER).

²Either video or audio will be selected.

⁴This paragraph will be included in the consent form for those interviews conducted offsite.

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑

OMB #0920-0222; Expiration Date: 01/31/2026

Attachment 4c – Parent/Guardian informed consent form for minors (virtual interviews)

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

Shape3 National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Informed Consent Form

Parent/Guardian Permission

One-on-One Virtual Interviews

Purpose of the Research

Surveys are used to collect information on the health and wellbeing of Americans. The surveys help to develop programs to improve the health and health care of people living in the United States.

Before health surveys are conducted, the questions are tested with people of different backgrounds. It is important that the questions make sense, are easy to answer, and that everyone understands the questions the same way. The National Center for Health Statistics (NCHS) conducts these tests for the surveys it sponsors and for other survey programs. If you permit your child to take part in this test, we will ask you to answer the survey questions. Then, we will ask you to explain what you were thinking and how you came up with your answers.

The questions we are working on today are about your child’s childhood experiences that can be positive (such as feeling safe or supported by friends) or negative (such as experiencing abuse or bullying). It is not necessary to have had these experiences to participate. The questions are being tested by NCHS on behalf of the National Center for Injury Prevention and Control (NCIPC).

Procedures

We ask that you complete a personal information sheet.

If you have questions about how the project works, contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470 3311 Toledo Rd., Hyattsville, MD 20782.

Recordings

We would like to video record your child’s interview. However, we will only retain the audio part of the recording. The audio recording allows us to more carefully study and improve the questions. If you agree, your child may still ask to stop the recording at any time, and we will stop recording. If your child decides to stop recording, we will ask his/her consent to retain the portion already recorded.

If you agree to record your child’s interview, we will keep the recording of your child’s interview in a locked room either in a secure storage cabinet or on a password-secured computer. Only researchers from the CCQDER, RSS, and [sponsor] working on the project will be allowed to listen to the recording. When in use all recordings will be in the safe keeping of a staff person from the CCQDER. In accordance with the CCQDER Data Storage and Access Policy, recordings will be retained for a minimum of two years, and they may be used for question evaluation research that is not directly related to this project.

You or your child may decide at any time after the interview that you don’t want us to keep a recording of the interview. In this case, you may contact Ms. Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470, 3311 Toledo Rd., Hyattsville, MD 20782. When she receives your request, the recording of your interview will be immediately destroyed.

Privacy

We are required by law¹ to tell you what we will do with the recording. We must also tell you how we will protect your child’s privacy.

Materials with personal facts (such as names or addresses) are also stored in a locked room or password protected. Only CCQDER staff has access to this material.

Your child’s name or other personal facts that would identify your child will not be used when we discuss or write about this study. People working on this project or those listening to the audio recording, however, may recognize your voice.

Benefits and Risks

There are no direct benefits to your child from taking part in this study.

The possible risks of your child taking part in this study are minimal. We will take all possible steps to protect your child’s privacy. Your child does not have to give us any information that he/she does not want to, and he/she can choose not to answer any question in the interview. He/she may also stop at any time and still receive the full $50. NCHS secures all information we collect, process and store on our systems as required by Federal regulations, Executive Orders, and NCHS confidentiality statutes. However, NCHS cannot secure and protect personal computing devices, such as personal computers or smart phones, used to complete the NCHS interview.

If you have any questions about this study, please call the office of 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 Project IDXX. [Note: The project ID will be inserted into the form once NCHS ERB approval has been received]. Your call will be returned as soon as possible.

Please Read and Sign Below if You Agree

ÿ I freely choose to allow my child to take part in this research study.

I allow NCHS to audio record my child’s interview. I also allow NCHS to play my child’s audio recording to researchers from CCQDER, RSS, and NCIPC, on-site at NCHS CCQDER.

ÿ Yes ÿ No

IF YES:

I allow NCHS to retain my child’s audio recording for future research on how people react to survey questions and how survey questions can be hard to understand or hard to answer. I also allow NCHS to play my child’s audio recording to internal NCHS CCQDER staff. I understand that the recording of my child’s interview will be kept for as long as it is of interest to researchers (a minimum of two years).

ÿ Yes ÿ No

______________________________ __________________________ __________

Parent/Guardian Signature Print Name Date

¹This paragraph will be included in the consent form for those interviews conducted at the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER).

²Either video or audio will be selected.

³The Public Health Service Act provides us with the authority to do this research (42 U.S.C 242k). 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(d)) and the Confidential Information Protection and Statistical Efficiency Act of (44 U.S.C. 3561-3583). 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. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

⁴This paragraph will be included in the consent form for those interviews conducted offsite.

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑

OMB #0920-0222; Expiration Date: 01/31/2026

Attachment 4d - Informed assent form for minors (virtual interviews)

D EPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

Shape4 National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Informed Assent Form

Young People

One-on-One Virtual Interviews

Purpose of the Research

The questions we are trying out today are about your childhood experiences that can be positive (such as feeling safe or supported by friends) or negative (such as experiencing abuse or bullying). It is not necessary to have had these experiences to participate. Your interview will help us to understand the different types of problems young people have answering these survey questions and will show us how to write better questions in the future.

NCHS is trying out the questions for the National Center for Injury Prevention and Control.

Procedures

We ask that you complete a personal information sheet.

If you have questions about how the project works, contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470 3311 Toledo Rd., Hyattsville, MD 20782.

Recordings

We would like to video record your interview, but we will only keep the audio part of the recording. The audio recording allows us to more carefully study and improve the questions. If you agree, you may still ask to stop the recording at any time, and we will stop recording. If you decide to stop recording, we will ask your assent to retain the portion already recorded.

We will keep the recording of your interview in a locked room, either in a secure storage cabinet or on a password-secured computer. Only researchers working on the project will be allowed to listen to the recording. When in use all recordings will be in the safe keeping of a staff person from the CCQDER. In accordance with the CCQDER Data Storage and Access Policy, recordings will be retained for a minimum of two years, and they may be used for question evaluation research that is not directly related to this project.

Privacy

We are required by law¹ to tell you what we will do with the recording. We must also tell you how we will protect your privacy.

Materials with personal facts (such as names or addresses) are also stored in a locked room or password protected. Only CCQDER staff has access to this material.

Benefits and Risks

There are no direct benefits to you from taking part in this study.

The possible risks of taking part in this study are minimal. We will take all possible steps to protect your privacy. You do not have to give us any information that you do not want to, and you can choose not to answer any question in the interview. You may also stop at any time and still receive the full $50. NCHS secures all information we collect, process and store on our systems as required by Federal regulations, Executive Orders, and NCHS confidentiality statutes. However, NCHS cannot secure and protect your personal computing devices, such as personal computers or smart phones, used to complete the NCHS interview.

If you have any questions about this study, please call the office of 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 Project IDXX. [Note: The project ID will be inserted into the form once NCHS ERB approval has been received]. Your call will be returned as soon as possible.

-------------------------------

¹This paragraph will be included in the consent form for those interviews conducted at the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER).

²Either video or audio will be selected.

⁴This paragraph will be included in the consent form for those interviews conducted offsite.

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑

OMB #0920-0222; Expiration Date: 01/31/2026

Attachment 5e – Adult informed consent for interviews conducted face-to-face

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

Shape5 National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Adult Informed Consent Form for

One-on-one Interviews

You are being asked to take part in a research study. This consent form tells you about the study and what you will be asked to do. You can choose to take part in the study or not. If you choose to take part, you will need to read this entire form and sign it.

Purpose of the Research

Surveys are used to collect information on the health and wellbeing of Americans. The surveys help to develop programs to improve the health and health care of people living in the United States.

Before health surveys are conducted, the questions are tested with people of different backgrounds. It is important that the questions make sense, are easy to answer, and that everyone understands the questions the same way. The National Center for Health Statistics conducts these tests for the surveys it sponsors and for other survey programs. If you agree to take part in this test, we will ask you to answer the survey questions. Then, we will ask you to explain what you were thinking and how you came up with your answers.

The questions we are trying out today are about your or your child’s childhood experiences that can be positive (such as feeling safe or supported by friends) or negative (such as experiencing abuse or bullying). It is not necessary to have had these experiences to participate. They are being tested on behalf of the National Center for Injury Prevention and Control (NCICP).

Your interview will show us how to improve the questions for this survey. In the future, we may also study your interview along with interviews from other projects. This type of study will teach us about the different kinds of problems people have answering survey questions. The study will help us write better questions in the future.

Procedures

We ask that you complete a personal information sheet.

If you have questions about how the project works, contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470 3311 Toledo Rd., Hyattsville, MD 20782.

Recordings

We would like to video/audio² record your interview. The recording allows us to more carefully study and improve the questions. At the bottom of this form, you will be asked if you are willing to have the interview recorded. If you agree, you may still ask to stop the recording at any time, and we will turn off the machine. If you decide to stop recording, we will ask your consent to retain the portion already recorded. When the interview is finished, you may watch/listen to the recording.

If you agree to record the interview, we will keep it in a locked room either in a secure storage cabinet or on a password-secured computer that is not connected to the internet. Only researchers from the CCQDER and RSS who are working on the project will be allowed to watch/listen to the recording in a secured room. When in use all recordings will be in the safe keeping of a staff person from the CCQDER. In accordance with the CCQDER Data Storage and Access Policy, upon project completion, the video of the interview will be destroyed. Audio recordings will be retained for a minimum of 2 years and may be used for question evaluation research that is not directly related to this project.

You may decide at any time after the interview that you don’t want us to keep a recording of the interview. In this case, you may contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5451, 3311 Toledo Rd., Hyattsville, MD 20782. When she receives your request, the recording of your interview will be immediately destroyed.

Privacy

We are required by law³ to tell you what we will do with the recording. We must also tell you how we will protect your privacy.

Audio and video recordings are stored in a locked room or secured by a password. All recordings are labeled by a code number, date, time, and project title. The recording is never labeled with your name or other personal facts.

Materials with personal facts (such as names or addresses) are also stored in a locked room. Only CCQDER staff has access to this material.

Your name or other personal facts that would identify you will not be used when we discuss or write about this study. People working on this project or those viewing the audiovisual recording or audio recording, however, may recognize you or your voice.

Benefits and Risks

There are no direct benefits to you from taking part in this study.

Conducting an interview at a mutual location⁴

For you to take part in the study today, we agreed to meet at this location. Meeting at this location is your choice. However, you are urged to choose a place that is private so that you will feel comfortable answering the questions. We will protect any materials that contain your personal information and transport them to the National Center for Health Statistics.

If you have any questions about this study, please call the office of 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 Project ID-XX [Note: The project ID will be inserted into the form once NCHS ERB approval has been received]. Your call will be returned as soon as possible.

Please Read and Sign Below if You Agree

ÿ I freely choose to take part in this research study.

When video recording is selected:

I allow NCHS to video record my interview. I also allow NCHS to play my video recording to researchers from NCICP, CCQDER and RSS on-site at NCHS CCQDER.

ÿ Yes ÿ No

IF YES:

I allow NCHS to retain my video recording for future research on how people react to survey questions and how survey questions can be hard to understand or hard to answer. I also allow NCHS to play my video recording to internal NCHS CCQDER staff. I understand that the recording of my interview will be kept for as long as it is of interest to researchers (two years).

ÿ Yes ÿ No

When audio recording is selected:

I allow NCHS to audio record my interview. I also allow NCHS to play my audio recording to researchers from NCICP, CCQDER and RSS on-site at NCHS CCQDER.

ÿ Yes ÿ No

IF YES:

ÿ Yes ÿ No

______________________________ __________________________ __________

Respondent Signature Print Name Date

¹This paragraph will be included in the consent form for those interviews conducted at the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER).

²Either video or audio will be selected.

⁴This paragraph will be included in the consent form for those interviews conducted offsite.

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑

OMB #0920-0222; Expiration Date: 01/31/2026

Attachment 4f: Adult informed consent for interviews conducted virtually

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

Shape6 National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Adult Informed Consent Form for

One-on-one Virtual Interviews

Purpose of the Research

Surveys are used to collect information on the health and wellbeing of Americans. The surveys help to develop programs to improve the health and health care of people living in the United States.

Before health surveys are conducted, the questions are tested with people of different backgrounds. It is important that the questions make sense, are easy to answer, and that everyone understands the questions the same way. The National Center for Health Statistics (NCHS) conducts these tests for the surveys it sponsors and for other survey programs. If you agree to take part in this test, we will ask you to answer the survey questions. Then, we will ask you to explain what you were thinking and how you came up with your answers.

The questions we are trying out today are about your or your child’s childhood experiences that can be positive (such as feeling safe or supported by friends) or negative (such as experiencing abuse or bullying). It is not necessary to have had these experiences to participate They are being tested on behalf of the National Center for Injury Prevention and Control (NCICP).

Procedures

We ask that you complete a personal information sheet.

If you have questions about how the project works, contact Amanda Titus by phone at (301) 458-4579, or by mail at NCHS, Room 5470 3311 Toledo Rd., Hyattsville, MD 20782.

Recordings

We would like to video record your interview. The recording allows us to more carefully study and improve the questions. If you agree, you may still ask to stop the recording at any time, and we will stop recording. If you decide to stop recording, we will ask your consent to retain the portion already recorded.

We will keep the recording of your interview in a locked room either in a secure storage cabinet or on a password-secured computer. Only researchers from the CCQDER and RSS contractors who are working on the project will be allowed to watch the recording. When in use all recordings will be in the safe keeping of a staff person from the CCQDER. In accordance with the CCQDER Data Storage and Access Policy, upon project completion, the video of the interview will be destroyed. Audio recordings will be retained for a minimum of [2] years and may be used for question evaluation research that is not directly related to this project.

Privacy

We are required by law¹ to tell you what we will do with the recording. We must also tell you how we will protect your privacy.

Video recordings are stored in a locked room or secured by a password. All recordings are labeled by a code number, date, time, and project title. The recording is never labeled with your name or other personal facts.

Materials with personal facts (such as names or addresses) are also stored in a locked room or password protected. Only CCQDER staff has access to this material.

Benefits and Risks

There are no direct benefits to you from taking part in this study.

The possible risks of taking part in this study are minimal. We will take all possible steps to protect your privacy. You do not have to give us any information that you do not want to, and you can choose not to answer any question in the interview. You may also stop at any time and still receive the full [$50]. NCHS secures all information we collect, process and store on our systems as required by Federal regulations, Executive Orders, and NCHS confidentiality statutes. However, NCHS cannot secure and protect your personal computing devices, such as personal computers or smart phones, used to complete the NCHS interview.

If you have any questions about this study, please call the office of 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 Project ID:XXXX [Note: The project ID will be inserted into the form once NCHS ERB approval has been received]. Your call will be returned as soon as possible.

-------------------------------

¹This paragraph will be included in the consent form for those interviews conducted at the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER).

²Either video or audio will be selected.

⁴This paragraph will be included in the consent form for those interviews conducted offsite.

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑

OMB #0920-0222; Expiration Date: 01/31/2026

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Titus, Amanda (CDC/DDPHSS/NCHS/DRM)
File Modified	0000-00-00
File Created	2025-05-19