Parental Consent

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix A-12: 2

Same-sex relationships: Updates to Healthy Marriage and Relationship Education Programming

Informed Consent for Participation:

[Name of Program] Parental Consent Form for the Participation of Minors

• Your son/daughter is invited to participate in a research study conducted by the Urban Institute, a non-profit research organization in Washington, D.C. This study is currently funded by the U.S. Department of Health and Human Services.

• This study focuses on the experiences of youth and adults in Healthy Marriage and Relationship Education programs.

• If allow your son/daughter to participate in this study, two facilitators from the Urban Institute will moderate a 90 minute focus group with 5-6 participants. The facilitators will ask questions relating to experiences with [program name]. These discussions will take place in a secure, private, and accessible location at a time that is convenient for you.

• Your son/daughter will be offered voluntary participation in the study, advised of the risks and benefits of participation, guaranteed privacy, and provided a small incentive of $25. Your son/daughter will sign an informed assent form and a receipt of incentive. These signatures will remain separate from any notes. We will not keep any identifying information in our records, such as full name, address, or phone number.

• Everything that is said during the discussion group is private. Your son/daughter will share only his/her first name during the focus group. His/her responses will never be linked to his/her name, or yours, in any written or verbal report of this research study. Your son/daughter will need to initial a receipt acknowledging receipt of the $25. This initialed form will remain locked away and will not be linked to his/her responses during the focus group.

• Your decision to allow your son/daughter to participate will not affect his/her or your relationship with the program or the Urban Institute.

If you have questions, comments, or concerns about this study, you may contact Program Manager Maeve Gearing at the Urban Institute, 2100 M Street NW Washington, DC 20037, at (202) 261-5156 or mgearing@urban.org or the Institutional Review Board Administrator who approved this research, Everett Madden, Madden, Everett at (202) 261-5632 or EMadden@urban.org. You may also contact the Federal Project Officer, Seth Chamberlain, in the Office of Planning, Research, and Evaluation at (202) 260-2242 or seth.chamberlain@acf.hhs.gov.

This information collection is voluntary and will be used to learn how Healthy Marriage programs serve clients. 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 number for this collection is 0970-XXXX and expires XX/XX/XXX.

Your signature below indicates that you have read the information provided above, have received answers to any questions, and have consented to your son/daughter’s participation in the study.

________________________________________

Printed name of son/daughter

_________________________________________ _________________________

Signature of parent or legal guardian Date