Consent Template: Combined HIPAA - The Children's Hospital of ...

Study Procedures:
We will ask you for your contact information (address, phone numbers and email
address) and that of two other friends so that we may be sure we can keep in touch with
you in the event you move. We will also ask you for the contact information of your
doctor and your school.
Growth Assessment
We will measure growth in a few different ways. For infants, some of these measures will
be taken without clothing. Children, teens and young adults will be measured wearing
shorts and a t-shirt, or a hospital gown or hospital scrubs. This will make it easier to get
correct measurements. Most measurements will be taken three times to get the most
accurate measurement. We will measure weight on an electronic scale. Babies will be
weighed on an infant scale and all others will be weighed on a standing scale.
For children less than two to three years of age, we will measure length, laying down on a
length board. One person will hold the baby’s head in the right position and another
person will stretch out their legs. We will then lift up the baby’s legs and measure from
their head to their bottom.
For children 2 to 3 years of age, and older, we will measure height using a “stadiometer”
which is how most pediatricians measure height. We also will measure body and head
height by having the child sit down on a stool with their body against the stadiometer.
This is called a “sitting height”.
Using a regular tape measure, we will also measure head size, waist size and upper arm
size. We will then measure skinfold thickness, which helps tell how much fat is
underneath the skin. Skinfold thickness will be measured in four places; on the front and
back of the arm, on the back and the belly. These measurements are taken with a
“skinfold caliper” which feels like a gentle squeeze when it takes the measurements.
It will take about 20 minutes to complete the growth measurements.
Questionnaires
Children and young adults seven years of age or older, and their caregivers will be asked
to complete a questionnaire about puberty (the changes in the body as children become
adults) based on a description sheet with pictures. Caregivers and young adults will also
be asked to fill out a few forms which ask about the following information:
• Age, race, and ethnicity and the kind of educational program the child or young
adult attends.
• Previous hospitalizations and surgeries or current medical problems, medications
the child is currently taking and has been on in the past.
• Sports or physical activities the child or young adult does each week as well as
how much time is spent in more passive activities, such as watching television or
playing electronic games.
• Age-appropriate questions about feeding problems.
• Parents/guardians will also provide some information about their education level,
household income and their height and weight.
Version 3
CHOP IRB#: IRB 09-007306
Approval Date: 11/8/2010
Expiration Date: 11/7/2011 Page 2 of 8