Appendix H - Consent forms NI Report NDNS - 2019-2023
Source: data.gov.uk (2025-10-10)

National Diet and Nutrition Survey 2017 to 2023 Report for Northern Ireland. This report presents results from 2017-2023 of the National Diet and Nutrition Survey (NDNS) for Northern Ireland. NDNS is a continuous cross-sectional survey, designed to assess the diet, nutrient intake and nutritional status of the general population aged 18 months and over living in private households in the UK.

Item_123_P16198 and P15224_NDNS_Data Linkage Consent Form_England_v5_01.12.2021. For use from 01.01.2022
NATIONAL DIET AND NUTRITION SURVEY Y14/Y15
CONSENT FORM: Linking survey answers to other information (ENGLAND)
The National Health Service (NHS) maintains medical and health records on all patients who use their services, such as:
• In-patient and out-patient visits to hospital, length of stay and waiting times
• Information about specific medical conditions such as cancer
• Details about when people pass away, the date and cause of their death.
The National Diet and Nutrition Survey has been running since 2008 and provides valuable information on what people eat 
and how this may affect their health. We would like to ask for your permission to add information from some medical and 
health records to the answers you have provided in the survey. The information we would like to add is from the
Hospital Episodes Statistics data, civil registration mortality data and Cancer Registration data (held by the appropriate 
governing body, currently NHS Digital). To link this information we need to send your name, address and date of birth to 
NHS Digital so they can identify your health records, and your health records would then be linked to the anonymised 
survey data, using a unique ID.
NHS Digital will provide the Hospital Episodes Statistics data, the civil registration mortality data and the Cancer 
Registration data.
By linking this information we can look at how a person’s lifestyle can have an impact on their future health. For example, 
if a person who took part in the National Diet and Nutrition Survey gets cancer or dies, the type of cancer or cause of 
death will be linked with their answers to the survey.
As we would like to look at long term trends in people’s health, we have not set a limit on how long we will keep your 
information.
This information will be used for statistical and research purposes only. The information will not identify you and it cannot 
be used by anyone treating you as a patient.
By signing this form you are only giving permission to link survey information to administrative health data (as detailed 
above), and nothing else. We will not be able to obtain any other details from your medical records.
You can cancel this permission at any time in the future by writing to: NatCen Social Research, 35 Northampton 
Square, London EC1V 0AX, or you can telephone: xx-xxxx-xxxx. You do not need to give a reason to cancel this.
For further information please visit: www.natcen.ac.uk/taking-part/studies-in-field/national-diet-and-nutrition-survey
Please tick
P15224.01/P16198.01 
OFFICE COPY
ADULTS 16+
I understand that information held and managed by NHS Digital may be used in order to provide information about my 
health status.
I understand that these details will be used for statistical and research purposes only.
Your consent:
I consent to my survey answers being linked to:	
Hospital Episodes Statistics data	
Civil registration mortality data	
Cancer registration data	
Participant signature
Interviewer signature
Date
Date
Participant name
Interviewer name

Item_123_P16198 and P15224_NDNS_Data Linkage Consent Form_England_v5_01.12.2021. For use from 01.01.2022
NATIONAL DIET AND NUTRITION SURVEY Y14/Y15
CONSENT FORM: Linking survey answers to other information (ENGLAND)
The National Health Service (NHS) maintains medical and health records on all patients who use their services, such as:
• In-patient and out-patient visits to hospital, length of stay and waiting times
• Information about specific medical conditions such as cancer
• Details about when people pass away, the date and cause of their death.
The National Diet and Nutrition Survey has been running since 2008 and provides valuable information on what people eat 
and how this may affect their health. We would like to ask for your permission to add information from some medical and 
health records to the answers you have provided in the survey. The information we would like to add is from the
Hospital Episodes Statistics data, civil registration mortality data and Cancer Registration data (held by the appropriate 
governing body, currently NHS Digital). To link this information we need to send your name, address and date of birth to 
NHS Digital so they can identify your health records, and your health records would then be linked to the anonymised 
survey data, using a unique ID.
NHS Digital will provide the Hospital Episodes Statistics data, the civil registration mortality data and the Cancer 
Registration data.
By linking this information we can look at how a person’s lifestyle can have an impact on their future health. For example, 
if a person who took part in the National Diet and Nutrition Survey gets cancer or dies, the type of cancer or cause of 
death will be linked with their answers to the survey.
As we would like to look at long term trends in people’s health, we have not set a limit on how long we will keep your 
information.
This information will be used for statistical and research purposes only. The information will not identify you and it cannot 
be used by anyone treating you as a patient.
By signing this form you are only giving permission to link survey information to administrative health data (as detailed 
above), and nothing else. We will not be able to obtain any other details from your medical records.
You can cancel this permission at any time in the future by writing to: NatCen Social Research, 35 Northampton 
Square, London EC1V 0AX, or you can telephone: xx-xxxx-xxxx. You do not need to give a reason to cancel this.
For further information please visit: www.natcen.ac.uk/taking-part/studies-in-field/national-diet-and-nutrition-survey
Please tick
I understand that information held and managed by NHS Digital may be used in order to provide information about my 
health status.
I understand that these details will be used for statistical and research purposes only.
Your consent:
I consent to my survey answers being linked to:	
Hospital Episodes Statistics data	
Civil registration mortality data	
Cancer registration data	
Participant signature
Interviewer signature
Date
Date
Participant name
Interviewer name
P15224.01/P16198.01 
PARTICIPANT COPY
ADULTS 16+

Item_142_NDNS_Spot urine sample_adult consent form_v5.0_01.12.2021. For use from 01.01.2022
National Diet and Nutrition Survey 
(NDNS) Spot Urine Sample
ADULT CONSENT FORM (16+ years)
MREC Reference Number: 13/EE/0016
STICK BARCODE 
LABEL HERE
1.  I confirm that I have read and understand the NDNS Spot Urine Collection 
information sheet(s) dated xx-xxxx-xxxx (version 5)/ 01.12.2021 (version 5.1) for 
the above study. I have been given the opportunity to ask questions and have 
had these answered satisfactorily.
2.  I understand that my participation is voluntary and that I am free to withdraw 
from the study at any time without giving a reason and without my medical care 
or legal rights being affected.
3.  I consent to provide a urine sample for the measurement of Iodine.
4.  I give permission for any remaining urine taken as part of this study to be stored 
and used in future research with necessary approvals as appropriate.
Please initial  
(or tick) boxes
MALE
SEX
PERSON No.
OFFICE COPY
ADULTS 16+
CHECK LETTER
SERIAL NUMBER
Please use capital letters and write in ink
SERIAL NUMBER 
FEMALE
When completed: bottom copy for participant; top copy for NatCen office
You can cancel this permission at any time in the future by writing to us at the following address:  
NatCen Social Research, 35 Northampton Square, London EC1V 0AX. Telephone: xx-xxxx-xxxx
Name of Participant (Please print)
Name of Interviewer (Please print)
Date
Date
Signature
Signature
D
D
M
M
Y
Y

Item_142_NDNS_Spot urine sample_adult consent form_v5.0_01.12.2021. For use from 01.01.2022
National Diet and Nutrition Survey 
(NDNS) Spot Urine Sample
ADULT CONSENT FORM (16+ years)
MREC Reference Number: 13/EE/0016
STICK BARCODE 
LABEL HERE
1.  I confirm that I have read and understand the NDNS Spot Urine Collection 
information sheet(s) dated xx-xxxx-xxxx (version 5)/ 01.12.2021 (version 5.1) for 
the above study. I have been given the opportunity to ask questions and have 
had these answered satisfactorily.
2.  I understand that my participation is voluntary and that I am free to withdraw 
from the study at any time without giving a reason and without my medical care 
or legal rights being affected.
3.  I consent to provide a urine sample for the measurement of Iodine.
4.  I give permission for any remaining urine taken as part of this study to be stored 
and used in future research with necessary approvals as appropriate.
Please initial  
(or tick) boxes
MALE
SEX
PERSON No.
PARTICIPANT COPY
ADULTS 16+
CHECK LETTER
SERIAL NUMBER
Please use capital letters and write in ink
SERIAL NUMBER 
FEMALE
When completed: bottom copy for participant; top copy for NatCen office
You can cancel this permission at any time in the future by writing to us at the following address:  
NatCen Social Research, 35 Northampton Square, London EC1V 0AX. Telephone: xx-xxxx-xxxx
Name of Participant (Please print)
Name of Interviewer (Please print)
Date
Date
Signature
Signature
D
D
M
M
Y
Y

 ADDRESS 
Please use capital letters and write in ink 
STICK  
NCON  
LABEL HERE  
(If providing 
blood sample) 
Nurse number: 
Full name (of person tested) 
Name by which GP knows person (if different) 
Sex 
Male 
Female  
1 
2 
Date of birth: 
DAY: 
MONTH: 
YEAR: 
Full name of parent/guardian (if person under 16) 
GP NAME AND ADDRESS (Please complete fully) 
 Dr: …………………………………………………………………. 
 Practice Name: …………………………………………………… 
 Address: ………………………………………………………….. 
 ……………………………………………………………………… 
 Town: ………………………………………………………………. 
 County: …………………………………………………………….. 
 Postcode: ………………………………………………………….. 
 Telephone no: ……………………………………………………. 
NURSE USE ONLY
  GP Address complete        1 
GP Address not complete        2 
  No GP        3 
1. 
Date schedule 
completed  
(all visits complete): 
DAY: 
MONTH: 
YEAR: 
2. 
3. 
4. 
5. 
6. 
7. 
8.
SUMMARY OF CONSENTS—RING CODE FOR EACH ITEM
a)
Read and understood the Stage 2 Information Sheet
b)
Understand right to withdraw
c)
Sample of blood to be taken
d)
Blood sample for storage
e)
Blood sample result to participant
f)
Blood sample result to GP
g)
Does not wish to receive results or have them sent to GP
h)
Agrees survey doctor can contact to discuss results if necessary
–Children aged 1.5-15 years
YES 
01 
03 
05 
07 
09 
11 
13 
15 
NO 
02 
04 
06 
08 
10 
12 
14 
16 
1. 
INDIVIDUAL SERIAL NUMBER: 
Please write in below: 
CHECK  
LETTER 
PERSON 
NO. 
FOR POST OFFICE (COOL BOX) DELIVERY PROTOCOL
Nurse: Please confirm whether a blood sample was obtained?   
 YES  
NO
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

BLOOD SAMPLE LIST 
The tables below show which blood samples should be taken (in 
priority order) and need to be sent to the lab for each age group: 
PARTICIPANTS AGED 16+  
PARTICIPANTS AGED 7-15  
 PARTICIPANTS AGED 18 mths – 6 yrs 
2. 
Priority 
Blood Tube 
Colour 
Label Reference
1 
EDTA K3 2.0 ml 
Lilac 
EN1 
2 
Serum TE 6.0 ml 
Royal Blue 
SEN1 
3 
Li Hep LH 6.0 ml 
Green 
LHN1 
4 
Serum TE 6.0 ml 
Royal Blue 
SEN2 
5 
Li Hep LH 6.0 ml 
Green 
LHN2 
6 
EDTA K3 4.0 ml 
Purple 
EN2 
Priority 
Blood Tube 
Colour 
1 
EDTA K3 2.0 ml 
Lilac 
EN1 
2 
Serum TE 6.0 ml 
Royal Blue 
SEN1 
3 
Li Hep LH 6.0 ml 
Green 
LHN1 
4 
Serum TE 6.0 ml 
Royal Blue 
SEN2 
Priority 
Blood Tube 
Colour 
1 
EDTA K3 2.0 ml 
Lilac 
EN1 
2 
Serum TE 6.0 ml 
Royal Blue 
SEN1 
3 
Li Hep LH 4.0 ml 
Green 
LHN1 
Label Reference
Label Reference
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
ADULT CONSENT FORM (16+ years) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
I confirm that I have read and understand the NDNS Stage 2 information sheet
(s) dated 12.08.2020 (v7.1) / 01.12.2021 (v8) for the above study. I have been
given the opportunity to ask questions and have had these answered
satisfactorily.
2.
I understand that my participation is voluntary and that I am free to withdraw
from any part of the study, at any time, without giving a reason and without my
medical care or legal rights being affected.
BLOOD SAMPLE 
Name of participant (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
3. 
Please initial/tick 
boxes if consent 
given 
You will be required to consent to the statement below if you do not 
want to receive your blood results AND if you do not want them sent to 
your GP. 
I confirm that against the advice of the NDNS survey team, I do not want to  
receive my blood results which are clinically relevant or have them sent to 
my GP. I understand that if there are findings outside of the normal range, 
this will not be brought to the attention of any health care provider. 
7. 
Name of participant (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
Office copy
3.
I agree to have a blood sample taken as part of the study.
4.
I give permission that my blood sample taken as part of this study may be stored
and used in future research studies with necessary approvals as appropriate.
5.
I would like to receive my blood results which are clinically relevant.
6.
I consent to my GP being notified of my blood results which are clinically relevant.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

4.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
ADULT CONSENT FORM (16+ years) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
I confirm that I have read and understand the NDNS Stage 2 information sheet
(s) dated 12.08.2020 (v7.1) / 01.12.2021 (v8) for the above study. I have been
given the opportunity to ask questions and have had these answered
satisfactorily.
2.
I understand that my participation is voluntary and that I am free to withdraw
from any part of the study, at any time, without giving a reason and without my
medical care or legal rights being affected.
BLOOD SAMPLE 
Name of participant (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
5. 
Please initial/tick 
boxes if consent 
given 
You will be required to consent to the statement below if you do not 
want to receive your blood results AND if you do not want them sent to 
your GP. 
I confirm that against the advice of the NDNS survey team, I do not want to  
receive my blood results which are clinically relevant or have them sent to 
my GP. I understand that if there are findings outside of the normal range, 
this will not be brought to the attention of any health care provider. 
7. 
Name of participant (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
Participant copy
3.
I agree to have a blood sample taken as part of the study.
4.
I give permission that my blood sample taken as part of this study may be stored
and used in future research studies with necessary approvals as appropriate.
5.
I would like to receive my blood results which are clinically relevant.
6.
I consent to my GP being notified of my blood results which are clinically relevant.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

6.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
PARENTAL/GUARDIAN CONSENT FOR CHILD (1.5-3 YEARS) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
I am the parent/guardian of the child named above and I confirm that I have
read and understand the NDNS Stage 2 information sheet(s) dated 12.08.2020
(v7.1) / 01.12.2021 (v8) for the above study. I have been given the opportunity
to ask questions and have had these answered satisfactorily.
2.
I understand that my child’s participation is voluntary and that s/he is free to
withdraw from any part of the study, at any time, without giving a reason and
without our medical care or legal rights being affected.
BLOOD SAMPLE 
3.
I agree to my child having a blood sample taken as part of the study.
4.
I give permission that my child’s blood sample taken as part of this study may
be stored and used in future research studies with necessary approvals as
appropriate.
5.
I would like to receive my child’s blood results which are clinically relevant.
6.
I consent to my child’s GP being notified of his/her blood results which are
clinically relevant.
IF you do not want to receive your child’s blood results AND if you do not 
want them sent to their GP, for us to take a blood sample from your child, 
you will be required to consent to both of the statements below. 
(i)
I confirm that against the advice of the NDNS survey team, I do not want
to receive my child’s blood results which are clinically relevant or have
them  sent to his/her GP.
(ii)
I agree to the survey doctor contacting me to discuss, if necessary, any
results that are directly relevant to my child’s health.
7. 
Name of Parent/Guardian (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
7. 
Name of Child 
Please initial/
tick boxes if 
consent given 
Name of nurse (please print) 
Date 
Signature 
Name of Parent/Guardian (please print) 
Date
Signature
Office copy
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

8.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
PARENTAL/GUARDIAN CONSENT FOR CHILD (1.5-3 YEARS) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
I am the parent/guardian of the child named above and I confirm that I have
read and understand the NDNS Stage 2 information sheet(s) dated 12.08.2020
(v7.1) / 01.12.2021 (v8) for the above study. I have been given the opportunity
to ask questions and have had these answered satisfactorily.
2.
I understand that my child’s participation is voluntary and that s/he is free to
withdraw from any part of the study, at any time, without giving a reason and
without our medical care or legal rights being affected.
BLOOD SAMPLE 
3.
I agree to my child having a blood sample taken as part of the study.
4.
I give permission that my child’s blood sample taken as part of this study may
be stored and used in future research studies with necessary approvals as
appropriate.
5.
I would like to receive my child’s blood results which are clinically relevant.
6.
I consent to my child’s GP being notified of his/her blood results which are
clinically relevant.
IF you do not want to receive your child’s blood results AND if you do not 
want them sent to their GP, for us to take a blood sample from your child, 
you will be required to consent to both of the statements below. 
(i)
I confirm that against the advice of the NDNS survey team, I do not want
to receive my child’s blood results which are clinically relevant or have
them  sent to his/her GP.
(ii)
I agree to the survey doctor contacting me to discuss, if necessary, any
results that are directly relevant to my child’s health.
7. 
Name of Parent/Guardian (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
9. 
Name of Child 
Please initial/
tick boxes if 
consent given 
Name of nurse (please print) 
Date 
Signature 
Name of Parent/Guardian (please print) 
Date
Signature
Participant copy
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

10.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

Please affix  
PCB DESP 
barcode 
 label here 
Nurse number: 
Blood sample Despatch Form  
DAY: 
MONTH: 
YEAR: 
DAY: 
MONTH: 
YEAR: 
TIME 
Sample Taken: 
Sample Taken: 
Date Posted: 
11. 
INDIVIDUAL SERIAL NUMBER: 
Please write in below : 
CHECK  
LETTER 
PERSON 
NO. 
Checklist 
1.
Samples
2.
Labels
3.
Temperature
indicator
4.
Despatch
note
Fasted sample 
YES
NO
Please tick participant age group and which samples you are sending: 
PT AGED 7-15 yrs 
Colour 
Label  
PT AGED 16+ 
Colour 
Label  
PT AGED 18 mths – 6 yrs  
Colour 
Label  
Lilac
Royal Blue
Green 
ONCE COMPLETED, PLACE INTO COOL BOX ON TOP OF 
THE POLYSTYRENE LID BEFORE SEALING THE BOX 
EN1
SEN1 
LHN1 
Lilac
Royal Blue
Green
Royal Blue 
EN1
SEN1 
LHN1
SEN2 
Lilac
Royal Blue
Green
Royal Blue
Green
Purple 
EN1
SEN1 
LHN1
SEN2
LHN2
EN2 
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

12.
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13.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

14. 
DESPATCH NOTE FOR ALL SAMPLES 
DESP OFFICE 
(OFFICE COPY) 
8.
Did you experience any problems in taking the Venepuncture? If yes, please
record these below and state what action you took. (PROMPTED FROM CAPI)
Please affix 
OFFDESP   
LABEL HERE 
(If providing 
blood sample) 
1.
Participant
details
2.
Age group:
16+ yrs 
 EDTA      Serum TE   Li Hep LH      Serum TE 
Li Hep LH  EDTA 
7-15 yrs
 EDTA 
Serum TE  Li Hep LH        Serum TE 
18mths – 6 yrs  
EDTA       Serum TE   Li Hep LH 
3.
Date blood sample taken:
4.
Time blood sample taken:
5.
Date blood posted:
6.
Time blood posted:
7.
Royal Mail Tracking number:
DAY: 
MONTH: 
YEAR: 
DAY: 
MONTH
YEAR: 
TIME 
: 
INDIVIDUAL SERIAL NUMBER: 
Please write in below: 
CHECK  
LETTER 
PERSON. 
No. 
TIME 
: 
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15.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
CHILD ASSENT FORM (5-15 years) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
Have you been shown the ‘What happens next leaflet
V5xx-xxxx-xxxx) / V5.1 (01.12.2021)’
2.
Has somebody explained what happens at the nurse visit?
3.
Do you understand what this study is about?
4.
Have you asked all the questions you want?
5.
Have you had your questions answered in a way you understand?
6.
Do you understand it’s OK to stop taking part at any time?
7.
Are you happy to take part?
If any answers are ‘No’ or you don’t want to take part, don’t sign your name! 
If you do want to take part, you can write your name below. 
Your name 
Date 
The nurse who explained this study to you needs to sign too: 
Nurse name 
Signature 
Date 
Please circle 
Yes / No 
Yes / No 
Yes / No 
Yes / No 
Yes / No 
Yes / No 
Yes/No 
Thank you for helping us! 
16
Participant copy
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17.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
CHILD ASSENT FORM (5-15 years) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
Have you been shown the ‘What happens next leaflet
V5xx-xxxx-xxxx) / V5.1 (01.12.2021)’
2.
Has somebody explained what happens at the nurse visit?
3.
Do you understand what this study is about?
4.
Have you asked all the questions you want?
5.
Have you had your questions answered in a way you understand?
6.
Do you understand it’s OK to stop taking part at any time?
7.
Are you happy to take part?
If any answers are ‘No’ or you don’t want to take part, don’t sign your name! 
If you do want to take part, you can write your name below. 
Your name 
Date 
The nurse who explained this study to you needs to sign too: 
Nurse name 
Signature 
Date 
Please circle 
Yes / No 
Yes / No 
Yes / No 
Yes / No 
Yes / No 
Yes / No 
Yes/No 
Thank you for helping us! 
18
Office copy
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19.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
PARENTAL/GUARDIAN CONSENT FOR CHILD (4-15 YEARS) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
I am the parent/guardian of the child named above and I confirm that I have
read and understand the NDNS Stage 2 information sheet(s) dated
12.08.2020 (v7.1) / 01.12.2021 (v8) for the above study. I have been given
the opportunity to ask questions and have had these answered satisfactorily.
2.
I understand that my child’s participation is voluntary and that s/he is free to
withdraw from any part of the study, at any time, without giving a reason and
without my child’s medical care or legal rights being affected.
BLOOD SAMPLE 
3.
I agree to my child having a blood sample taken as part of the study.
4.
I give permission that my child’s blood sample taken as part of this study may
be stored and used in future research studies with necessary approvals as
appropriate.
5.
I would like to receive my child’s blood results which are clinically relevant.
6.
I consent to my child’s GP being notified of his/her blood results which are
clinically relevant.
IF you do not want to receive your child’s blood results AND if you do not 
want them sent to their GP, for us to take a blood sample from your child, 
you will be required to consent to both of the statements below. 
(i)
I confirm that against the advice of the NDNS survey team, I do not want
to receive my child’s blood results which are clinically relevant or have
them  sent to his/her GP.
(ii)
I agree to the survey doctor contacting me to discuss, if necessary, any
results that are directly relevant to my child’s health.
7.
Name of Parent/Guardian (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
20.
Please initial/
tick boxes if 
consent given 
Name of Child 
Name of Parent/Guardian (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
Participant copy
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

21.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

National Diet and Nutrition Survey (NDNS) Nurse Visit 
PARENTAL/GUARDIAN CONSENT FOR CHILD (4-15 YEARS) 
MREC Reference Number: 13/EE/0016 
Please use capital letters and write in ink 
SERIAL NUMBER 
CHECK LETTER 
PERSON NO. 
1.
I am the parent/guardian of the child named above and I confirm that I have
read and understand the NDNS Stage 2 information sheet(s) dated
12.08.2020 (v7.1) / 01.12.2021 (v8) for the above study. I have been given
the opportunity to ask questions and have had these answered satisfactorily.
2.
I understand that my child’s participation is voluntary and that s/he is free to
withdraw from any part of the study, at any time, without giving a reason and
without my child’s medical care or legal rights being affected.
BLOOD SAMPLE 
3.
I agree to my child having a blood sample taken as part of the study.
4.
I give permission that my child’s blood sample taken as part of this study may
be stored and used in future research studies with necessary approvals as
appropriate.
5.
I would like to receive my child’s blood results which are clinically relevant.
6.
I consent to my child’s GP being notified of his/her blood results which are
clinically relevant.
IF you do not want to receive your child’s blood results AND if you do not 
want them sent to their GP, for us to take a blood sample from your child, 
you will be required to consent to both of the statements below. 
(i)
I confirm that against the advice of the NDNS survey team, I do not want
to receive my child’s blood results which are clinically relevant or have
them  sent to his/her GP.
(ii)
I agree to the survey doctor contacting me to discuss, if necessary, any
results that are directly relevant to my child’s health.
7.
Name of Parent/Guardian (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
22.
Please initial/
tick boxes if 
consent given 
Name of Child 
Name of Parent/Guardian (please print) 
Date 
Signature 
Name of nurse (please print) 
Date 
Signature 
Office copy
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

23.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022

24.
Item_n66_NDNS_Nurse visit consent booklet_combined_PO_v7.0_01.12.2021. For use from 01-04-2022