Form 6 Attachment N Pre-Post Feedback Study Child Assent Form

OMB Control Number: 0925-XXXX Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 5 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.

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 development of a new educational website.

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 project?

We want to get your help on a new educational website for kids your age. We are asking you to complete a few questionnaires to help us learn more about you and to help us see how well you like our new website.

What will I have to do?

You will be asked to:

1. Complete a questionnaire to let us know a little bit about yourself and your beliefs,

2. Review the new website, and

3. Complete a final questionnaire about your beliefs and your opinions of the new website.

This study may take up to 4 hours in total and you will get a break whenever needed. Your parent/ caregiver has given permission for you to help us, but you still decide for yourself if you want to do it or not.

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.

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 do not have to answer any of the questions or participate in any of the activities that you don’t want to. You can choose to quit this project at any time.

Are there any risks to being in the project?

We do not think there are any real risks to you. If you don’t want to, you don’t have to participate in the study.

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

You will help us to make a website that can help a lot of youth, like yourself.

Will I get anything for being in the project?

For participating in this project, you will receive $50.

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

The project is being done by Dr. Alison Parker and Dr. Tracy Scull of innovation, Research, & Training. If at any point during your participation in this project, you have any additional questions or concerns, you or your parent can contact Dr. Parker, at (919) 493-7700, email: aparker@irtinc.us or Tracy Scull, at (919) 493-7700, email: tscull@irtinc.us.

If you have any questions or concerns about your rights as a research participant or how you were treated, you or your parent should contact Barbara Goldman, Ph.D., Chair of the iRT Institutional Review Board (IRB), which reviews studies like this one, at barbara_goldman@unc.edu or 919-966-7169.

Thank you for your help!

Sincerely,

Alison Parker, Ph.D. Tracy Scull, Ph.D.

Co-Principal Investigator Co-Principal Investigator

innovation Research &Training innovation Research & Training

Feedback Study

YOUTH AGREEMENT

In this study, you will be asked to:

• Answer some questions about yourself and your beliefs

• Review a new website

• Provide feedback on what you see in the website

You do not have to be in the study if you don’t want to, and you can stop being in the study at any time. You do not have to answer any questions that you don’t want to answer. Your answers will be kept private.

Yes, I would like to be a part of the Feedback Study.

Child’s Name (please print) Date

Your Caregiver’s Name (please print) Date

Please keep one copy of this 4-page form and turn in the other one with your name on it.

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