Attach_g123

2012-15 NSFG

Attachment G1

0920-0314

Attachment G1: Advance Letter for Households
From the Director of the National Center for Health Statistics:
My agency, part of the U. S. Department of Health and Human Services, needs your help.
We are doing an important research study called the National Survey of Family Growth.
The main part of this study asks questions about family life, marriage and divorce, having
and raising children, health and health care. The information is used to help improve
health services and health education programs.
To prepare for this study, we are asking a scientific sample of households to take part in a
short interview. We have asked the University of Michigan to do these interviews for us.
In a few days, an interviewer will visit your home to complete the interview. The visit
will only take about 5 minutes, and any adult who lives in the home can answer. You
may be asked to complete our main interview, which is described in more detail in the
enclosed brochure.
Your help is voluntary but is key to the success of the study. By Federal law*, the
answers you give are confidential and we will take all possible steps to protect your
privacy. Your answers will be used for research only.
We look forward to speaking with you soon.
I thank you for your help with this influential study.

Sincerely,

Edward J. Sondik, Ph.D.
Director, National Center for Health Statistics
http://www.cdc.gov/nchs

*One important law that protects your confidentiality is Section 308(d) of the Public Health Service Act
(42 USC 242m(d)). The other two laws are the Confidential Information Protection and Statistical
Efficiency Act of 2002 (44 USC 3501 note) and the Privacy Act of 1974 (5 USC 552a). Section 306 of the
Public Health Service Act (42 USC 242k) allows us to carry out this survey.

2012-15 NSFG

Attachment G1

0920-0314

Attachment G1: Advance Respondent Letter
From the Director of the National Center for Health Statistics:
We are pleased that you were chosen to take part in the National Survey of Family Growth. This
important research study is being done by the National Center for Health Statistics of the United States
Department of Health and Human Services.
We plan to speak to a national sample of households. The interview asks questions about family

life, marriage, divorce, cohabitation, family planning, fatherhood, infertility, pregnancy and
birth. It lasts about 60-80 minutes, and you will only be asked questions that apply to you. The
information is used to help improve health services and health education programs.
The highly respected University of Michigan will do the interviews.
Your help in this study is voluntary but is also helpful to the success of the study. Saying yes or no to
being in the study will not change any benefits you get now or in the future. The interview is
interesting and enjoyable for most people. Each person interviewed represents thousands of others.
Your interviewer will arrange to do the interview at a time that works best for you. For your help, you
will receive $40 as a token of appreciation.
By Federal law*, the answers you give are confidential and we will take all possible steps to protect
your privacy. Your answers will be used for research only. We report the information in summary
form. Individuals or families can not be identified. You may choose not to answer any question at any
time. You may have questions about your rights as a participant in this research study. If so, please call
the office of the Research 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 Study Number 2011-11. Your call will be returned as soon as possible.
The enclosed brochure will help to answer your questions about the study. You can also learn more at
our website: www.cdc.gov/nchs/nsfg.htm. To schedule your interview, please call the University of
Michigan (toll-free) at 1-800-759-7947.
I thank you for your help with this influential study.
Sincerely,

Edward J. Sondik, Ph.D.
Director, National Center for Health Statistics
http://www.cdc.gov/nchs
*One important law that protects your confidentiality is Section 308(d) of the Public Health Service Act (42 USC
242m(d)). The other two laws are the Confidential Information Protection and Statistical Efficiency Act of 2002
(44 USC 3501 note) and the Privacy Act of 1974 (5 USC 552a). Section 306 of the Public Health Service Act (42
USC 242k) allows us to carry out this survey.

2012-15 NSFG

Attachment G3

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

0920-0314
Centers for Disease Control and Prevention
National Center for Health Statistics
3311 Toledo Road
Hyattsville, Maryland 20782

Attachment G3: Adult Permission Form
ADULT’S PERMISSION FOR INTERVIEW
This interview is part of the National Survey of Family Growth. This research study is being done for the U.S. National Center
for Health Statistics. The University of Michigan will do the interviews. The interview asks questions about marriage, divorce,
adoption, cohabitation, family planning, fatherhood, infertility, sexual experience, and pregnancy and birth. The information
will be used to help improve health services and health education programs in the U.S. The interviewer will only ask questions
that apply to you. The interview lasts about 60-80 minutes. Answers to the questions will be entered into a laptop computer.
You will be part of a scientific sample of people. You will represent thousands of other people across the country. Your
participation is very important because it will help the study be accurate for people like yourself. For your help in this study, you
will receive $40 as a token of appreciation.
By Federal law, the answers you give are confidential and we will take all possible steps to protect your privacy. Your answers
will be used for research only. To keep the answers confidential it is important to do the interview in a private setting. This
brochure, which you may have seen earlier, answers questions people sometimes ask about the study.
Your help in this study is completely voluntary. Saying yes or no to being in the survey will not change any benefits you get
now or in the future. For most people, the survey is interesting and enjoyable. Some of the questions in the interview may be
sensitive for some people. You may choose not to answer any question for any reason, and you may stop the interview at any
time.
You may have questions about your rights as a participant in this research study. If so, please call the office of the Research
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 Study Number 2011-11. Your call will be returned as soon as
possible. If you have other questions about the survey, you may call Dr. William Mosher or Dr. Gladys Martinez (toll-free) at
NCHS: 1-866-227-8347, or visit the NSFG webpage: www.cdc.gov/nchs/nsfg.htm.
Thank you again for being part of our survey.
I have read the study letter and brochure. I agree to take part in the survey.
I received the $40 token of appreciation. 
_________________________________
Respondent’s Signature

I refused the $40 token of appreciation. 
________________________________
Respondent’s Name (PLEASE PRINT)

_________________________________
Interviewer’s Signature

I have read the study letter and brochure. I agree to take part in the survey but do not wish to sign this consent form. 
Interviewer: The respondent has read the study letter and brochure or they have been read to the respondent. The respondent
has given oral permission to be interviewed, but does not wish to sign the consent form.
_________________________________
Interviewer’s Signature

2012-15 NSFG

Attachment G3

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

0920-0314
Centers for Disease Control and Prevention
National Center for Health Statistics
3311 Toledo Road
Hyattsville, Maryland 20782

Attachment G3: Parent Permission Form
PARENT’S/GUARDIAN’S PERMISSION FOR INTERVIEW
This interview is part of the National Survey of Family Growth. This research study is being done for the U.S. National Center
for Health Statistics. The University of Michigan will do the interviews. The survey has questions on family life, marriage,
family planning, sexual experience, pregnancy, health and use of health care, and attitudes and opinions about these topics. The
interviewer will only ask questions that apply to your son or daughter’s experience. The information will be used to help
improve health services and health education programs in the U.S. The interview lasts about 60 minutes. Answers to the
questions will be entered into a laptop computer.
Your son or daughter will be part of a scientific sample. This sample will represent the 20 million teenagers in the United States.
His or her participation is very important and will help the study results to be accurate for all teenagers. Your teenager will
receive $40 as a token of appreciation for his or her help in this study.
By Federal law, your teenager’s answers are confidential and we will take all possible steps to protect your teenager’s and your
family’s privacy. Your teenager’s answers will be used for research only and will not be shared with you or other family
members. To keep the answers confidential it is important to do the interview in a private setting. This brochure, which you
may have seen earlier, answers questions people sometimes ask about the study.
Giving your permission does not mean that your son or daughter has to do the interview. It just means that we have your
permission to ask him or her for the interview. Your son or daughter is free to decide to do the interview or not. Saying yes or
no to being in the survey will not change any benefits you or your teenager gets now or in the future. For most people, the
survey is interesting and enjoyable. Some of the questions in the interview may be sensitive for some people. Your son or
daughter may choose not to answer any question for any reason, and he or she may stop the interview at any time.
You may have questions about your teenager’s rights as a participant in this research study. If so, please call the office of the
Research 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 Study Number 2011-11. Your call will be returned
as soon as possible. If you have other questions about the survey, you may call Dr. William Mosher or Dr. Gladys Martinez
(toll-free) at NCHS: 1-866-227-8347, or visit the NSFG webpage: www.cdc.gov/nchs/nsfg.htm.
I have read the study letter and brochure. You may ask my son or daughter if he or she wants to take part in the survey.
_________________________________
Parent’s/Guardian’s Signature
____________________________________
Son or Daughter’s Name (PLEASE PRINT)

________________________________
Parent’s/Guardian’s Name (PLEASE PRINT)

2012-15 NSFG

Attachment G3

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

0920-0314
Centers for Disease Control and Prevention
National Center for Health Statistics
3311 Toledo Road
Hyattsville, Maryland 20782

Attachment G3: Assent form for Minors
MINOR’S PERMISSION FOR INTERVIEW (AGE 15-17)
We are doing a research study called The National Survey of Family Growth. Your parent or guardian says that you may take
part. This study is being done for the U.S. National Center for Health Statistics. The University of Michigan does the
interviews. The survey has questions on family life, marriage, family planning, sexual experience, pregnancy, health and health
care. We also ask your thoughts about these topics. The interviewer will only ask questions that make sense for you. The
information will be used to help improve health services and health education programs for teens and adults. The interview lasts
about 60 minutes. Answers will be put into a laptop computer.
You will be part of a sample that represents the teenagers in the U.S. Your help is very important because you represent
thousands of others. To thank you for your help in this study, we will give you $40.
By Federal law, the answers you give are confidential and we will take all possible steps to protect your privacy. We will not
share them with your parents or other family members. They will be used for research only. To keep the answers private we
will do the interview in private. This brochure answers questions people sometimes ask about the study.
It’s your choice to do the interview or not. Saying yes or no to being in the survey will not change any benefits you get now or
ever. For most people, the survey is interesting and enjoyable. Some of the questions in the interview may be sensitive for some
people. You can say no to any question for any reason. You can stop at any time.
You may have questions about your rights as a participant in this research study. If so, please call the office of the Research
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 Study Number 2011-11. Your call will be returned as soon as
possible. If you have other questions about the survey, you may call Dr. William Mosher or Dr. Gladys Martinez (toll-free) at
NCHS: 1-866-227-8347, or visit the NSFG webpage: www.cdc.gov/nchs/nsfg.htm.
If you agree to take part in this study, please sign this form. Thank you again for being part of our survey.
I have read the study letter and brochure. I agree to take part in the survey.
I received the $40 token of appreciation. 
_________________________________
Respondent’s Signature
_________________________________
Interviewer’s Signature

I refused the $40 token of appreciation. 
________________________________
Respondent’s Name (PLEASE PRINT)