Attachment E_STREAMS_Parent consent form

ATtachment e

parental consent form for youth participation

This page intentionally left blank for double sided copying

Form Approved

OMB Number:

Expiration Date:

Dear Parent or Guardian,

The Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (DHHS) is conducting a study examining the effectiveness of healthy marriage and relationship education programs (HMRE) designed to improve intimate relationships. The Strengthening Relationship Education and Marriage Services (STREAMS) Evaluation will investigate how these programs impact both youth and adults. ACF has hired Mathematica Policy Research, an independent policy research firm, to conduct this study.

Your child’s school is taking part in this study, and ninth-grade students, including your child, are being asked to participate. We are asking your permission for your child to participate in the study. Research staff from Mathematica will do two surveys of study participants over the next year. These surveys include questions about your child’s friends, family, community, and education, and also about your child’s attitudes, knowledge and activities, including sexual activity. If you give permission for your child to participate in the study, he/she will complete the first survey in fall 2016 in school. We will only follow-up over the telephone or email if your child is absent from school during our visit. The next survey will be conducted in fall 2017. Mathematica will again administer the survey in the schools, and will only follow-up over the telephone or email if your child is no longer enrolled in his/her current school or if they are absent from school during our visit. The study team will also gather information about your child’s attendance in any classes at school that he or she participates in that provide information on healthy marriages and relationships. Your child might also be asked to participate in a focus group discussion later. If your child is selected for a focus group, you will be asked to provide permission for his/her participation at that time.

All information collected for the study will be kept private to the fullest extent allowed by law. If you let your child participate, your child’s information will be combined with information from other youth. Your child’s name will not be attached to the answers he/she gives, and no one outside the study team will see his/her answers.

Participation in the study is voluntary. If you agree that your child can participate, you or your child can choose to stop participation at any time with no consequences. The only risk to your child connected with the study is that he/she may be uncomfortable answering some questions in the surveys. If that happens, your child can refuse to answer those questions. Your child will receive a $15.00 gift card for completing the second survey next year. There are no additional benefits to your child participating in the study.

Please let us know whether you will allow your child to be in the study by completing and signing the attached form. If you have questions about the STREAMS Evaluation or about your participation, please call Shawn Marsh, Mathematica’s Survey Director, toll-free, at 1-xxx-xxx-xxxx between 9 a.m. and 5 p.m. Eastern Time, Monday- Friday.

Sincerely,

Robert Wood, PhD

Project Director, Mathematica Policy Research

Strengthening Relationship Education and Marriage Services (STREAMS)

Parent or Guardian Permission Form – Study

[SITE NAME]

Sponsored by the United States Department of Health and Human Services

I have read the attached information sheet describing the study. By signing this form, I am saying:

YES, I give permission NO, I do not give permission

for my child, _____________________________________, to participate in the study.

Print Child’s Name

In giving permission for my child to participate, I understand that Mathematica staff will administer two surveys to my child over the next year. I further understand that additional information will be collected through class attendance records. By giving permission for my child to be in the study, I agree that this information can be collected, and that my child may receive a text message to arrange for participation in the follow-up survey in fall 2017. I understand that participation is voluntary and may be withdrawn at any time for any reason without penalty. I further understand that all information on my child will be kept private and used only for the purposes of the study. If I have questions about my child’s rights as a research volunteer, I can call the New England Institutional Review Board, toll-free at 1-800-232-9570.

Parent or Guardian Signature: _______________________________ Date: _______________

Child’s Name: ___________________________ Child’s Date of Birth: _____ / ______ / _____

Month Day Year

If you said YES above, please fill in the following information. We will use your contact information only if we need your help in contacting your child to schedule a study survey next year. We also ask you to provide contact information for someone who would know how to reach you in the event you move and we cannot contact you. If we contact this person, we will not reveal any information about your child or the study, other than to say we need to locate your child to complete a survey. Thank you.

Parent or Guardian Name: ______________________________________________________________________

Street Address: _______________________________________________________________ Apt: ___________

City: _____________________________________________________ Zip Code: __________________________

Telephone: (______)_____ - ___________ Home Email: _________________________________

(_____) _____ - ____________ Work

(_____) _____ - ____________ Cell

Alternate Contact Name: _______________________________________________________________________

Street Address: _______________________________________________________________ Apt. ___________

City: _____________________________________________________ Zip Code: ________________________

Telephone: (_____) ____ - ___________ Home Email: _________________________________

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Parents please be aware that under the Protection of Pupil Rights Act. 20 U.S.C. Section 1232(c)(1)(A), you have the right to review a copy of the questions asked of your child. If you would like to do so, you should contact Shawn Marsh toll-free at 1xxx-xxx-xxxx to obtain a copy of the questions.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to examine the effectiveness of healthy marriage and relationship education programs designed to improve intimate relationships. 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 XXXX-XXXX and it expires on XX/XX/XXXX.

WE NEED YOUR ANSWER, WHETHER IT IS YES OR NO.
PLEASE SIGN AND RETURN TO YOUR CHILD’S HEALTH CLASS WITHIN ONE WEEK. THANK YOU!