ct:

 Survey

Nutrition Examination Survey 

Examination Assent Brochure, 7-11 years of age 

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics 
1 

The National Health and Nutrition Examination Survey 

(NHANES) studies the health and diet of people in this 

country. 

We go all over the United States in these vans. 

The survey will look at how young people grow and develop. 

We will look at special health problems that may affect 

kids. 

National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey

2 

Our survey wants you to come to this exam center. Your 

exam will help us find out more about the health of children 

your age. 

We will ask questions about

what you eat and drink. 

You will change into special

exam clothes at the exam 

center. 

National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey

3 

Our doctor will take your 

blood pressure. 

2 

3 

4 

5 We will see how much you


weigh and how tall you are.


Our dentist will look at 

your teeth. 

National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey

4 

We will check your blood and 

urine in our lab. 

+ 

We will send you and your 

parents a report on your 

exam. 

1 

1 $ 

E2958459G 

E2958459G 

We will give you money to 

thank you for helping us Our staff will answer any 

with our survey. questions you have. 

We would like you to go to our mobile exam center vans for an exam. You will 

help us learn more about all children in the United States. 

If you are 8 years or older, we will ask you about your feelings and about how 

you have been doing at home and school. Your mother (or other grown-up) will 

be called to answer these same questions about you. 

National Health and Nutrition Examination Survey
final consent forms 4 3/27/02, 11:24 AM

_________________________________________________________ 

_________________________________________________________ 

_________________________________________________________ 

___ ___ ___ ___ ___ ___

If you want to take part in the survey, write your name below. 

Signature of participant 7-11 years old 

Print name of participant 

Signature of staff member Date 

SP ID 

Public reporting burden of this collection of information is estimated to average 6.6 hours per response for total participation, includin

for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewin

collection of information. An agency may not conduct or sponsor, and a person is not required to respond to collection of information 

displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection 

information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1800 Clifton Road, MS D-24, 

GA 30333, ATTN: PRA (0920-0237). 

04-0258 (4/04) 
y

DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Examination Assent Brochure, 7-11 years of age 

act: 

n Survey