Attachment F
Young Adult Consent
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Consent to Be in a Research Study
The Centers for Disease Control and Prevention (CDC) wants to know about teen health and behavior. Since you are between 15 and 19 years old, we are asking you to take part in this survey. Questions will ask about your feelings and behaviors including sex and drug use. Some questions will ask about family and friends. You will use a computer to do the interview. It will take about 45 minutes. Please ask questions if there is anything you do not understand.
There are no direct benefits to you for answering these questions. You may feel awkward when answering questions. You will use headphones and a laptop to help keep your answers private.
You do not have to be in this study. If you agree to be in this study, we will offer you $20. You will be offered $20 even if you do not finish the questions.
Your answers will be kept private to the extent allowed by law. Your parents will not see your answers. All of your answers will be kept as secure as possible by the interviewer. Your answers will be sent to secure systems at the main study office. Your answers will not be shared outside the project. Your name will not be kept with your answers. Your answers will be mixed with others answers from other teens. At the end of the study, we will delete names and addresses. Your answers will not be connected to any information that could identify you.
There are some times when we cannot promise to keep your name private. If you tell the interviewer that you plan to hurt yourself or someone else, the interviewer will have to tell someone that can help like the police or your parent. Interviewers have to obey laws about reporting abuse to the authorities.
Your participation in this study is voluntary. If you take part, you do not have to answer every question. You can also stop answering questions at any time. This will not affect any benefits you usually receive. This will not affect any benefits your parents usually receive.
If you answer the questions, you might be called in the future. You will be given a copy of this form for your records.
If you have any questions about this study you can call Chad Rodi from ICF International at (877) 736-7911. If you feel like you have been harmed by being in the study, also call ICF International at (877) 736-7911. If you have any questions about your rights as a research volunteer you can call CDC Agency for Toxic Substances and Disease Registry’s Human Research Protection Office. Their phone number is (800) 584-8814. Leave a message with your name, and phone number. During that call refer to CDC protocol #6097, and someone will call you back.
I read this form, or it has been read to me. I understand what it says. My questions (if any) have been answered. I agree to take the survey.
Signature
Date
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Informed Consent – Caregiver |
| Author | Gordon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |