Parental Consent Form

HISD CHILD HEALTH SURVEY

We are asking that your child take part in a research study being done by Dr. Quianta Moore at Rice University in Houston, TX.

If you choose to allow your child to be in the study, your child will complete a survey. The survey will contain questions about your child’s physical, behavioral/mental and social needs. We are asking everyone within the HISD district to complete a survey to better understand the needs of children.

The survey will take about 20 minutes to complete.

Your child can skip questions that he or she does not want to answer or stop the survey at any time. The survey is anonymous, and no one will be able to link your child’s answers back to him or her. Please tell him or her not to include his or her name or any other information that could be used to identify him or her in the survey responses.

The survey will be conducted on an anonymous, secure online format that is HIPAA approved for protecting the respondent's private information.

This research study is voluntary. Please tell the school or researcher if you do not want to participate.

Question Title

* Typing your name and the date below represents your signature affirming that you agree that the above information has been explained to you and all your current questions have been answered. You understand that you may ask questions about any aspect of this research study during the course of the study and in the future. By signing this form, you agree that your child may participate in this research study.

Full Name:

Date:

Child's Name:

Question Title

* Minor's Assent

Typing his or her name and the date below represents your child's signature affirming that this research has been explained to him or her and that he or she agrees to participate.

Minor's name:

Date:

Please contact Dr. Quianta Moore at 713-348-4629 for questions related to the research. For questions about your rights as a research participant, or to discuss problems, concerns or suggestions related to the research, or to obtain information or offer input about the research, contact Stephanie Thomas, Compliance Administrator, at Rice University. Email: irb@rice.edu or Telephone: 713-348-3586

Question Title

Question Title

* Minor's AssentTyping his or her name and the date below represents your child's signature affirming that this research has been explained to him or her and that he or she agrees to participate.

* Minor's Assent

Typing his or her name and the date below represents your child's signature affirming that this research has been explained to him or her and that he or she agrees to participate.