Attachment H - 3M Assent Form for Teens

OMB Control Number: 0970-0355

Expiration Date: 1/31/2015

PARTICIPANT ID:________

Healthy Marriage Models and Measures- High School Age Adolescents Cognitive Interview Assent Form

Child Trends is doing a research study with teens for the Administration for Children and Families in the U.S. Department of Health and Human Services. The research will help us develop questions that could be used in healthy marriage and relationship education (HMRE) programming and evaluation. This form has information to help you decide if you want to be in the study.

1. GOAL:

We are trying to create questions that HMRE programs can use to find out if their program worked. Most of these questions relate to relationship skills and behaviors because HMRE programs try to help teens learn about healthy relationships.

2. WHAT WILL YOU NEED TO DO:

If you agree to be a part of the study, we will interview you for an hour and a half. During the interview, we will ask you questions about the relationships among teens. We will ask you to:

• Tell us about the meaning and wording of questions;

• Talk about how clear the questions are;

• Tell us about any problems you have understanding the questions; and

• Give ideas about how to word questions

As a thank-you, you will receive a $50 gift card at the end of the interview.

3. RISKS AND/OR DISCOMFORTS:

The main risk is the possibility of a loss of privacy. To protect your privacy, your name will not be used in reports. Your individual responses will not be shown to anyone outside of the study team. Some questions may make you uncomfortable. If we ask a question you do not want to answer, you can let the interviewer know and she will move on to the next question.

4. VOLUNTARY PARTICIPATION:

You can stop the interview at any time. If you finish the interview and then decide that you do not want to participate, you can let the interviewer know. You can also call Shelby

Hickman at (240) 223-9341 to be removed from the study.

4. PRIVACY:

Everything you tell us will remain as private as possible. We will combine what you and others tell us. This will help to reduce the chance that anyone can be identified when the study results are described. Only approved study staff will have access to the tape recordings and written notes. All recordings and written notes will be kept private to the extent permitted by law.

There are limits to privacy. If someone on the study team feels that keeping information private would result in danger to you or another person, they will have to tell proper agencies. The types of information that would not remain private include any reports of the abuse or neglect of a child or any thoughts you may have to hurt yourself or anyone else.

4. COSTS AND BENEFITS:

There are no costs from the study other than the time of the interview. You will not benefit personally from being in the study.

4. QUESTIONS:

If you have any comments or concerns about this study, you can call Dr. Mindy Scott, Principal Investigator, at (240) 223-9324. You can contact the Child Trends Institutional Review Board at: (855) 288-3506; irbparticipant@childtrends.org; or by writing to 7315 Wisconsin Avenue Suite 1200W Bethesda, MD 20814.

I have read the study described above and have been given a copy of it. I agree to take part in the study.

Confirmation of Agreement: _______________________________ _________________________

Interviewer Signature Date

I have also read that if someone on the study team feels that keeping information private would result in danger to me or another person, they will have to tell proper agencies to protect me or the other person.

Confirmation of Agreement: _______________________________ _________________________

Interviewer Signature Date

We would like to tape record the interview so that we can make sure that we don’t miss anything you say. We will also be taking notes. Please try not to use any identifying information (such as a full name) once we start recording.

Please know that you can still take part in the study even if you do not wish to be recorded.

Do we have your permission to tape record and transcribe the interview? YES NO

We also would like to use specific quotes from your interview in describing some of our results. However, all identifying information such as names or birthdates would be removed. Your identity will remain private. Please know that you can still participate in the study even if you do not want quotes from your interview used. You will have a chance to change your mind at the end of the interview as well.

Do we have your permission to use specific quotes from your interview in summaries, reports, and presentations of our study findings? YES NO

_____________________________ _________________________

Interviewer Signature Date

The Paperwork Reduction Act Burden Statement: This collection of information is voluntary and will be used to learn more about questions that may be used in healthy marriage and relationship education programming and evaluation. Public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0355 and it expires 01/31/2015.

Attachment H- 3M Assent Form for Teens