Form 2 Child Assent

Attachment 15

Child Assent Form

Public reporting burden for this collection of information is estimated to average 10 minutes per response,

including the time for reviewing instructions, searching existing data sources, gathering and maintaining

the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect

of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance

Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do

not return the completed form to this address.

OMB #: 0925-NEW

Expiration Date: 09/13/2014

innovation Research & Training, Inc.

Address: 1415 W. NC Highway 54, Suite 121, Durham NC 27707

Voice: 919 493-7700 Fax: 919 493-7720

Dear Youth,

We are asking you to help us with the Family Media Project.

This letter contains information to help you decide if you want to help us. Please ask as many questions as you want to be sure you understand what will happen and what you will do.

What is the purpose of this research project?

We want to know more about how you and your family use media together. Media are things like computers, televisions, video games, and cell phones. In this research project we want to see how you and your parents play a computer program together. Some computer programs may be CD-based and others may be on the Internet. We want to know if you find the program fun, interesting, and easy to use with your parent. Your thoughts will help us make the program better for families. Also, we want to know your thoughts about and use of alcohol and tobacco products.

What will I have to do?

1. You and your parent will meet with a project staff member, and you will both be asked to take a questionnaire.

2. You and your parent will be given a computer game to play together over a month.

3. You and your parent will take another questionnaire a month after you completed the first one.

4. You and your parent will meet with a project staff member to take a final questionnaire three months later.

Your parent will be with you at all times. She/he has given permission for you to help us, but you still decide for yourself if you want to do it or not. The questionnaire asks about your thoughts, ideas, and behaviors. This includes your thoughts about and use of alcohol and tobacco products, use of media, and ideas about advertising. Your questionnaire is separate from the one your parent will do. You can skip any question that you do not want to answer and quit at any time that you want for any reason.

Will my answers be kept private?

Yes, all of your answers will be kept private. Your name will not be on anything we keep for this project.

OMB #: 0925-NEW

Expiration Date: 09/13/2014

What happens if I don't participate in the project?

You do not have to be in this project unless you want to. If you decide to be in the project, you can skip any question that you do not want to answer and quit at any time that you want for any reason.

Are there any risks to being in the project?

No, we do not think there are any real risks to you. As we have said, you can skip any question that you do not want to answer and quit at any time that you want for any reason.

Will anything good happen as result of being in this project?

This project’s goal is to create a program that could help a lot of families, like yours. Your help will improve this program.

Will I get anything for being in the project?

For participating in this project, your family will receive a $20 gift for finishing the 1^st set of questionnaires; a $5 gift for completing the assigned computer program; a $30 gift for completing the 2^nd set of questionnaires one month later; and a $40 gift for completing the questionnaires 3 months after that. We are asking your family to help us for a total of about 12 hours over a 4-month period, so we think it is only fair if we provide these tokens of our appreciation to your family.

Who should I contact if I have any questions about the project?

The project is being done by Dr. Tracy Scull and Dr. Janis Kupersmidt of innovation, Research, and Training, Inc. If you have any questions about this project that were not answered, you or your parent may contact Dr. Scull, at (919) 493-7700, email: tscull@irtinc.us.

If you feel upset about how the project was run, you or your parent may contact Barbara Goldman, Ph.D., Chair of the iRT Institutional Review Board (IRB), at barbara_goldman@unc.edu or 919-966-7169.

Thank you for your help!

Sincerely,

Tracy Scull, Ph.D. Janis Kupersmidt, Ph.D.

Principal Investigator Co-Investigator

OMB #: 0925-NEW

Expiration Date: 09/13/2014

Family Media Project

YOUTH ASSENT

In this study, you will be asked to:

• Try out a computer program

• Complete three questionnaires

Participation is voluntary and participants can stop at any time. All responses will be kept private.

Yes, I agree to participate in the study.

Your Name (please print) Date

Your Parent’s Name (please print)

You will get a copy of this letter to keep.