Parent permission

ATTACHMENT H 
Parental Permission Form for KnowledgePanel® Members  
with an Eligible Minor‐Aged Child 

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This page is intentionally blank. 

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Parental Permission Form for KnowledgePanel® 
Members  with an Eligible Minor‐Aged Child 
[LOGOS: HHS and IPSOS]
Introduction
We would like your child, [NAME and AGE], to take part in an online survey of his or her
knowledge of male and female fertility and views on having children. About 4,000 adolescents
and young adults (15 to 29 years) are being randomly selected and invited to take part in this
study.
If you give permission for your child to participate, your child must also agree by clicking on a
separate form that states he or she agrees to take part.
What is the purpose of this study?
The survey is being conducted by the U.S. Department of Health and Human Services (HHS)
Office of Population Affairs (OPA) to learn about what young men and women know about
human fertility and their views on having children.
Why was my child selected for this study?
Your child was selected to take part in this study through a two-part process. First, your
household was randomly selected to represent many others like it in the country. Second, your
child is in the age group (15 to 17 years) that is being asked to participate in this study. This
means your child’s answers will represent the answers that many other young people like your
child would give if they were in the study too.
What does my child’s participation involve?
We’d like your child to complete one survey that has questions about their knowledge of male
and female fertility, their views on having children, and related behaviors. Your child will be
asked to answer these questions on their own and in private. Your child can answer these
questions on a computer, laptop, tablet, or smartphone. The survey will take your child about 20
minutes to answer all the questions. We’ll ask your child questions on these topics:
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Knowledge of female and male fertility issues
Views on childbearing and their intentions or goals for having children
Use of alcohol and cigarettes
Health insurance coverage and use of medical care services
Personal experiences with sex and pregnancy
Individual characteristics (examples: race, ethnicity, marital/relationship status)
If applicable, use of birth control methods

We ask that your child answer these questions in private. While answers to all questions are
important to the study, your child may skip any questions they prefer not to answer. The only
exception is that there are a few questions near the beginning of the survey about your child’s
biological ability to have children, your child’s sex as recorded on their birth certificate, and your
child’s age that your child must answer in order for the survey to proceed. If your child chooses
to skip these items, he or she will not be able to complete the survey.

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Can I or my child change our minds about participating?
Yes. Participating in the survey is voluntary. Your child may stop anytime. This will not affect
your or your child’s ability to participate in future surveys.
What are the possible benefits and risks of participating in the study?
Participating in this survey will not benefit you or your child directly. However, their answers
will be used to better understand young people’s knowledge about fertility and views on having
children, and to provide them with information to help them make better decisions for
themselves.
Taking this survey involves no risk of injury. Your child may experience temporary discomfort
or embarrassment with one or more of the survey’s questions on such topics as pregnancy, sexual
activity, contraceptive use, or alcohol use. If your child feels uncomfortable about any of the
questions, it’s OK to skip those questions, as noted above.
How will you protect my privacy and my child’s privacy?
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The survey will not collect any information that can link you or your child to their answers
(such as your name, their name, address, e-mail address).
The personal identifying information (name, address, e-mail address) that you and your
child have already shared as part of your membership in KnowledgePanel will not be
shared with the study researchers or the study sponsor. KnowledgePanel will continue to
secure your personal information in a protected computer file.
Your child will never be identified in any analysis, reports, or publications based on their
responses, and no one will try to sell you or your family anything.

A Certificate of Confidentiality has been obtained from the Federal Government for this study to
help insure your and your child’s privacy. This Certificate means that the researchers may not
disclose information that may identify you or your child, even by a court subpoena, in any
federal, state, or local civil, criminal, administrative, legislative or other proceedings. You should
understand that a Certificate of Confidentiality does not prevent you from voluntarily releasing
information about yourself, your child, or your child’s involvement in this research. The
Certificate cannot be used to resist a demand for information from personnel of the United States
Government that is used for auditing or program evaluation by the agency (Office of Population
Affairs) funding this study. The Certificate of Confidentiality will not be used to prevent
disclosure for any purpose you have agreed to in this document.
How will you keep my child’s information confidential?
Ipsos has processes in place designed to keep answers to surveys confidential. Your child can
answer the survey questions on a computer, laptop, tablet, or smartphone. Although the
guarantee of confidentiality of data transmitted on the Internet cannot be absolute, your child’s
answers will be transmitted and saved in a secure way to prevent viewing by anyone who does
not have permission to do so, and to prevent loss, alteration, or misuse of their answers.
Will my child receive anything for participating in this study?
In appreciation for your child’s participation, your child will receive 5,000 points ($5
equivalent), which will be credited to your account.

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Who can I contact if I have additional questions?
If you have any questions about taking part in this survey, you can contact the Panel Member
Support Center at the toll free number 1-800-782-6899 or send an e-mail to
support@knowledgepanel.com.
If you have any questions about this study, you may call Dr. Christina Fowler at 1-800-334-8571
(extension 23447). If you have any questions about your child’s rights as a study participant, you
may call RTI’s Office of Research Protections using toll-free number 1-866-214-2043.
Permission to Participate
By clicking on the box below, you give your permission for your child to take part in this survey.
Parent/Guardian Statements
YES

Yes, I give permission for my child to take part in this study.
Please give your device to your child or send the survey link below to your
child’s personal device. Before your child can complete the survey, he or she
must also agree to take part by clicking a box on a form to record their agreement.
If they agree to participate by clicking “YES,” the survey will begin
automatically.
Link to Survey: INSERT LINK

NO

No, I do not give permission for my child to take part in this study.

THANK YOU

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