bf Parent Consent Form

Tab G: Parent/Guardian Consent Form

Dear Parent/Guardian:

The school based health clinic is participating in a multi-site research project being run by Health Systems Research, Inc. under contract with a Federal Government Office of Women’s Health. The school based health clinic is introducing materials designed to help a young woman and her health care provider talk about and set goals around physical activity and healthy eating. This clinic is helping to determine whether these materials were useful.

This assessment is being conducted at six locations across the United States and approximately 2,400 young and adult women will take part. The assessment will examine how well the materials work.

We would like to ask the young woman for whom you are the parent or guardian to take part in this assessment when she goes to the school based health center for her annual health checkup.

She will be asked to fill out a form after she sees a health care provider. It will take her about 25 minutes to fill out the form. She will not put her name on the form. If she decides to fill out the form, she can stop at any time. If she decides not to fill out the form or only to fill out parts of it, it will not change the health care that she will get in the future at the school based health clinic.

This young woman may not gain anything from filling out this form. We do not think that filling out this form has any risks. All of the information she puts on the form will be kept private. It will be stored in a locked file cabinet at our offices in Washington, DC. Because names will not be on the form, there will be no way to link individuals to their answers.

If you have questions, please call me, Ms. Rebecca Ledsky, at Health Systems Research, Inc., at 202-776-5136. You can also call XXX at the school based health clinic with questions. If you have any questions about this young woman’s rights under this assessment you can call the Institutional Review Board representative XXX at 301-xxx-xxxx.

If you agree to let this young woman participate, please sign and date this form below.

Thank you very much.

Rebecca Ledsky

Principal Investigator

Health Systems Research, Inc.

Signature of Parent/Guardian: ___________________________________________________

Printed Name of Parent/Guardian: _______________________________________________

Not Valid Without IRB Approval Stamp on Last Page