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Appendix B Consent forms and information sheets on blood and EMLA cream Appendix B Consent forms and information sheets on blood and EMLA cream Consent forms GP notification consent form Z1 GP notification letter Z2 Blood pressure Z3 Blood sample Z4 NHSCR flagging Z5 Blood sample Blood sample information leaflet L4 List of blood analytes L5 EMLA Cream - information sheet X1 EMLA Cream screening question H EMLA Cream prescription form X3 Z1 Tel: 0171 533 5387/8 DUNN NUTRITION UNIT Tel: 01223 420959 NATIONAL DIET AND NUTRITION SURVEY: YOUNG PEOPLE AGED 4 TO 18 YEARS GP NOTIFICATION Address label (if incorrect - use serial number label and write in correct address) Today’s date Day Month Year Name of young person:........................................................................................................... (BLOCK CAPITALS) Mr/Mrs/Miss/Ms/Master First name Surname Marital status: Single / Married Gender: Male / Female Date of birth Age last birthday : years Day Month Year Name of parent/ guardian: ................................................................................................................... (BLOCK CAPITALS) Mr/Mrs/Miss/Ms First name Surname Address (if different from young person’s address) : .............................................................................. ............................................................................................................................................................... ............................................................................................................................................................... Postcode GP DETAILS: Name of young person’s GP: Dr................................................................................ (BLOCK CAPITALS) Address of GP:....................................................................................................................................... ................................................................................................................................................................ ................................................................................................................................................................ Postcode Telephone number (incl. Area Code):.................................................................................................... Interviewer use only Ring one code Consent to notify GP given 1 No GP 2 Consent to notify GP refused 3 Wave 3/4 Copies:GP/ DNU /ONS DUNN NUTRITION UNIT Tel: 0171 533 5387/8 Tel: 01223 420959 Z2 Dear Dr. ........................................... National Diet and Nutrition Survey: Young People aged 4 -1 8 Years I am writing to let you know that the young person, whose details are given on the enclosed form, and who is one of your patients, has agreed to take part in the forthcoming National Diet and Nutrition Survey. For young people under the age of 18 years, still living at home, permission to take part in the study will have been given by their parent or legal guardian. This survey of young people is the third in a programme of surveillance of diet and nutrition which will eventually cover the whole age range of the population. The survey has been commissioned jointly by the Departments of Health and the Ministry of Agriculture, Fisheries and Food and is being carried out by the Office for National Statistics with the Medical Research Council’s Dunn Nutrition Unit. The Dental Schools at the Universities of Birmingham and Newcastle are collaborating in those parts of the survey concerned with the oral health of the young people. The survey will include a random sample of about 2000 young people living in private households in Great Britain. Fieldwork will take place from January to December 1997. I am enclosing a leaflet which has been left with the young person and their family describing the aims and what is involved. As part of the survey young people are asked to co-operate in providing a blood sample and having their blood pressure measured. The Dunn Nutrition Unit is responsible for all the procedures associated with obtaining and analysing the blood samples. These will be analysed for haemoglobin and ferritin concentrations and for other diet- related analytes. Consent will be sought, depending on the age of the young person, from themselves or their parent/guardian for me to pass on the results of the blood sample analyses and the blood pressure measurement to you at a later date. The subjects are advised that such information becomes part of their medical record and will not be revealed in medical reports by you without their permission. I can assure you that the protocol for this survey has been examined and approved by the Local Research Ethics Committee of your Area Health Authority, Director for Primary Care or the equivalent in your local Health Authority, Directors of Public Health (CAMO’S in Scotland), Education and Social Services. The protocol has also been approved by Royal College of Paediatrics and Child Health. Your Chief Constable has also been informed that the survey is taking place, although not of the names of the young people taking part. The procedures included in this survey were all previously used successfully in a recently completed feasibility study. We have been asked by the Royal College of Paediatrics and Child Health to offer EMLA cream for the venepuncture. We shall request information from the subjects about any anaesthetic allergies. I may contact you if I require any more detailed information. If you know of any relevant information, please contact me via the Survey Office. I hope that this covering letter provides sufficient explanation for you; should you require any further information please contact Mrs. Adrienne Griffin, telephone number 01223 420959, who will be pleased to help you. Yours sincerely, Lisa Jackson BSc (Nutrition), MRCGP, DCH Survey Doctor enc: Z3 Tel: 0171 533 5387/8 DUNN NUTRITION UNIT Tel: 01223 420959 NATIONAL DIET AND NUTRITION SURVEY: YOUNG PEOPLE AGED 4 TO 18 YEARS BLOOD PRESSURE CONSENT FORM Serial number label Name of young person:...................................................................................................... Gender: M / F Age last birthday Date of birth Day Month Year Name of parent/guardian: Mr/Mrs/Miss/Ms.................................................................... (BLOCK CAPITALS) I .............................................................................................................................. (BLOCK CAPITALS) Mr/Mrs/Miss/Ms · understand that this survey is designed to add to medical knowledge which will help other young people; · have read the information about the survey, have had time to consider it, and have had the survey explained to me to my satisfaction; · have been told that I may withdraw my consent to any or all of the survey elements at any time, without needing to give a reason, and without prejudice to further medical treatment; · have been told that none of the results from the survey will be presented in any way that can be associated with the name and address of anyone in this household; · have been given a telephone number for further information about the survey, which is 01223 420959 (Dunn Survey Office); and hereby consent to the Dunn Nutrition Unit informing the above-named young person’s GP of their blood pressure measurement. For young person aged 4 -15 years: Signature of parent/guardian........................................................................ Date............................ .. For young person aged 16 - 17 years: Signature of young person........................................................................... Date.............................. and, if living at home Signature of parent/guardian....................................................................... Date.............................. For young person aged 18 years: Signature of young person........................................................................................................ Date.............................. PLEASE RECORD BLOOD PRESSURE RESULTS BELOW BP readings Systolic (mm Hg) . Diastolic (mm Hg) 1st reading® 2nd reading® 3rd reading® Wave 2 Copies: DNU/Subject/ONS Z4 Tel: 0171 533 5387/8 DUNN NUTRITION UNIT Tel: 01223 420959 NATIONAL DIET AND NUTRITION SURVEY: YOUNG PEOPLE AGED 4 TO 18 YEARS BLOOD SAMPLE CONSENT FORM Serial number label Name of young person: ........................................................................................................................... Gender: M / F Age last birthday Date of birth Day Month Year Name of parent/guardian: Mr/Mrs/Miss/Ms.................................................................. (BLOCK CAPITALS) I ................................................................................................................................ (BLOCK CAPITALS) Mr/Mrs/Miss/Ms · understand that this survey is designed to add to medical knowledge which will help other young people; · have read the information about the survey, have had time to consider it, and have had the survey explained to me to my satisfaction; · have been told that I may withdraw my consent to any or all of the survey elements at any time, without needing to give a reason, and without prejudice to further medical treatment; · have been told that none of the results from the survey will be presented in any way that can be associated with the name and address of anyone in this household; · have been
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