TPP Replication Study Baseline-RtRCuidate consent revised 05.14.12

Form Approved

OMB No. 0990-NEW

Exp. Date xx/xx/20xx

Parent/Guardian Permission Form for Youth Participation in the

Teen Health Empowerment Study

Reducing the Risk/¡Cuidate!

We would like your child to be part of an important study. The study will learn about how schools and communities can help young people make healthy decisions and avoid risky behaviors. This form gives information about the study. At the end of the form, you can tell us whether or not you would like your child to participate. It is really important that you read and return this form.

What is the study about? The goal of the study is to find out if a program called Reducing the Risk/¡Cuidate! does a good job helping young people like your son/daughter develop the positive attitudes and skills they need to make healthy choices about engaging in sex. It is delivered by a trained health educator. The program stresses the value of delaying having sex and the need to protect against unwanted pregnancy and sexually-transmitted infections, if they choose to be sexually active.

Who is doing the study? This research project is sponsored by the Office of the Assistant Secretary for Planning and Evaluation and the Office of Adolescent Health in the US Department of Health and Human Services (HHS).The evaluation is being conducted by Abt Associates Inc., a private research firm founded in 1965 in Cambridge, Massachusetts, and their research partner Decision Information Resources (DIR).

What will my son/daughter be asked to do if he/she takes part in the study? The study lasts for 24 months. If you agree that your child can be in the study, they will be asked to complete three on-line surveys. For each survey, he/she will be asked some questions, and the questions will take about 30 minutes to answer. Each time he/she finishes a survey, they will get a gift card. Over the period of 24 months, they could get a total of $75 in gift cards.

The first survey will be taken on a computer during class. For the second and third surveys, the study team will send your child a link to a secure survey website, so that they can take the surveys in a private place that they choose, like at home or in the library. As part of the evaluation, your child may also be invited to participate in a small group discussion (or focus group) about his/her experiences in the Reducing the Risk/¡Cuidate! program. At any time, you or your child may freely decide to no longer participate in the study.

What kinds of questions do the surveys ask? The surveys will have questions about your child’s experiences in school and community activities, about your family, and about sexual activity. Your child will only be asked questions about behaviors they have already engaged in; the computer will skip questions if they do not apply to your child.

How will you contact my child for the surveys? When you give consent and your child agrees to be part of the evaluation, the survey will ask for names and contact information of relatives and friends who can help us contact your child if you move during the study period. The project team will keep in touch with him/her to update their contact information and to remind them of upcoming surveys. We may invite her to join the Teen Health Empowerment Study page on Facebook. If they do so, other study participants may see that they are also a study participant. They don’t have to join the Facebook page- it is their choice.

What are the potential benefits and risks if we participate? There are no direct benefits to you or your child. However, your child’s participation will help us learn more about effective ways to prevent teen pregnancy. There is very little risk for your child to participate in this study. He or she may feel uncomfortable answering some personal questions on the survey. Your son or daughter can decide not to answer survey questions. They can decide to stop being in the study at any time.

Your child is not required to be in the study in order to take any of his/her classes. If you or your child decides not to be part of the evaluation, it is OK. Saying no to the study will not negatively affect you, your child, or your relationship to your child’s school.

Privacy. We will keep your child’s answers to the survey questions private, as much as the law allows us to. Only the people doing the evaluation will know their name and contact information. No one else will see their answers to the survey, and all personal information, like their name and contact information, will be kept separate from their survey answers.

We train all project staff to follow strict rules to protect your child’s privacy. Family members, including parents and legal guardians, will not see your child’s survey answers or get information with their name attached. There is little risk of their survey answers and personal information being seen by people who do not have permission, but we have many safety measures in place to prevent this from happening.

The researchers doing the study will never identify people in the study or people at the schools in their reports. When we write a report, the information that your child gives us will be combined and reported with information from all the people in the evaluation. We will share the survey data—that means all the answers from the surveys—with the funder, authorized researchers and the program. But we will exclude names and contact information, so no one can tell what your child’s survey answers are.

To further help protect the research project, we have a special certificate from the U.S. Department of Health and Human Services. It is called a Certificate of Confidentiality. It adds special protection for the information that identifies your child, like their name, address, or phone number. It says that we do not have to tell anyone who your child is. It says we do not have to tell anyone that your child is in the study. Even if a judge asks us to, we can say no. The only time that we may have to tell someone is if we find out that your child or someone else could be in danger.

We will do everything we can to protect your child’s privacy. But it is important that you and your family protect your privacy too. If you want other people to learn about your child’s participation in the evaluation and you ask us to share your information, we will do that – but only if you ask.

Who should I contact if I have questions about the study? If you have any questions about the study, please contact Meredith Kelsey, Abt Associates Study Director, at 617-520-2422 (toll call). For questions about your rights or your child’s rights in the study, please call Teresa Doksum, at Abt Associates at 877-520-6835 (toll-free call).

Please print your child’s name, print your name, sign your name and write the date on the form below. Please return one copy of the completed form to your child’s teacher, and keep the other copy for your records. Thank you for your cooperation in this important project.

Parent/Guardian Permission. Below, you have two options: 1) agree to allow your child to participate in the study, with a chance to receive the Reducing the Risk/¡Cuidate! program; or 2) refuse the study and any opportunity for your child to receive the program.

Permission to Participate in Study

I have read and understood the description of the study being conducted by Abt Associates/DIR. I understand that the information will be used ONLY for the purpose of the evaluation and will be kept strictly private, to the extent provided for by law.

 Yes, I agree to allow my child to participate in the study and have a chance to receive Reducing the Risk/¡Cuidate! I allow the researchers conducting this study to collect three surveys from my child, and to ask my child to update his or her contact information during the course of the study.

 No, I do NOT agree to allow my child to participate in the study.

Print YOUR CHILD’S Name: __________________________________________________________________________

First Last

Print YOUR Name: __________________________________________________________________________

First Last

Your Signature: ____________________________________________ Date: __________

55 Wheeler Street  Cambridge, Massachusetts USA  02138-1168  617 492-7100 telephone  617 492-5219 facsimile

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