0990-TPP evaluation Attachment E_youth assent

Attachment E

Youth Assent

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

Assent to Be in a Research Study

We want you to be in a study to find out more about teen behaviors. We would like to ask you questions about you, your family, and friends. We will also ask about behavior like drug or alcohol use and sex.

We talked to your parent and he or she has said you can answer the questions. The survey will take about 45 minutes. You will take the survey on the computer with headphones to help keep it private.

If you start the survey we will offer you $20. You will be offered $20 even if you do not finish the survey.

If you have any questions you can ask your parents or the interviewer.

Your answers will be kept as private as possible. Your parents will not see your answers. Your name will be kept private. Your answers will be mixed with other teens for reports. We will never use your name in reports. We will delete all names and addresses after the study ends.

There are some times when we cannot keep your name private. If you tell the person who interviews you that you plan to hurt yourself or someone else, she/he will have to tell someone that can help like the police or your parent. We must obey all laws about reporting abuse to the authorities.

If you finish the survey, you might be contacted to learn about your survey-taking experience. You will be given a copy of this form.

When you press the “I agree” button to start the survey you will be agreeing with this:

I have read this or it has been read to me, and I understand it. My questions have been answered. I will not be in trouble if I do not want to be in the study or if I quit. I do not have to answer questions I do not want to answer. If I change my mind and quit, my answers will be destroyed.