National Child Traumatic Stress Initiative (NCTSI) Evaluation Sample Informed Consent—Youth Assent Version (Suggested Content and Wording)
Purpose
(NCTSN center program name) has programs to help children and their families recover from trauma. (NCTSN center program name) and other places receive money from the U.S. government so we can learn how to make our programs better. We would like you to participate in this project because you are involved in a program at (NCTSN center program name).
Description of Participation
When you start treatment, someone at (NCTSN center program name) will ask you some questions. After three months, someone at (NCTSN center program name) will ask you some questions again. You will be asked some questions every three months until you are no longer in treatment. Then, someone at (NCTSN center program name) will ask you some questions one last time.
You will be asked questions about your thoughts and feelings. You will also be asked questions about how you act at home and at school. There are no right or wrong answers. This will take about 2 hours.
Risks and Benefits
You will not receive any gifts or money for answering these questions. At times, you may feel uncomfortable talking about your thoughts and feelings. If you need to, you can talk to (NCTSN center person name).
Confidentiality
What you tell us during these interviews will be kept private. When we write reports or talk about this study to other people, we will never use your name or tell them who you are. There is only one time we have to tell a few people who you are. We must tell if we think you are in a very dangerous situation. For example, we need to tell the police if someone is hurting you very badly.
Rights Regarding Decision to Participate
If you don’t want to be in this study, you don’t have to participate. Remember, being in this study is up to you and no one will be upset if you don’t want to participate or even if you change your mind later and want to stop.
I have read this form or, it has been read to me, and I understand what it says. My questions have been answered. A copy of this form will be given to me. By signing my name below, I freely agree:
to be interviewed every 3 months, until treatment end:
Name of the Child (Type or Print Full Name): ______________________________________
Signature of Child:
________________________________________ Date: ___/___/____
I, ___________________________, have read the preceding and agree to the participation of my child.
(Caregiver/Guardian) Name:_____________________________ Date: ___/___/____
Caregiver’s Signature: ____________________________ Date: ___/___/____
Project Name Team’s Certification
I certify that I have explained to the above individual the nature and purpose of the project as well as the potential benefits and risks associated with participating in the project. I also have answered any questions that have been raised and witnessed the above signature.
Signature of Witness: _____________________________ Date: ___/___/____
Funding
source Local
NCTSN center/program name Description
of why the study will be conducted Participant
responsibilities Description
of data collection methods: interviews--frequency, duration; record
review; observation, etc. Description
of child/youth involvement Other
guidelines (e.g., possible data sources, age, changes in
participation over time, etc. Potential
risk factors associated with participation Potential
benefits that may be gained through participation
Type
and amount of compensation participant will receive for
participation Process
or schedule for payment
Contact
information for someone working on the study who will be available
to answer participant questions Protocol
for maintaining participant privacy Description
and purpose of the Federal Certificate of Confidentiality Mandated
reporting requirements
Rights
Regarding Decision to Participate Statement
of participant rights to terminate participation at will Statement
that the termination of participation will not lead to adverse
consequences
Statement
of participant understanding of the consent form Statement
that participant has had all of his or her questions answered Permission
to be interviewed Permission
to access service provider records for 12 months previous to
service and 24 months after the first service Signature
line for participant to sign, thus granting consent to participate Date
Key
Components of a Consent Form
Elements
to Include:
Purpose
of the Study
Description
of Participation
Risks
and Benefits
Compensation
for Participation
Contact
Information
Protection
of Information
Voluntary
Consent
February 2010 NCTSI Evaluation-Youth Assent Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Bhuvana.Sukumar |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |