Consent

Consent Form for Participation

Teen Health Empowerment Study Discussion Group

We are so excited that you want to participate in a small group discussion as part of the Teen Health Empowerment study. The purpose of these discussions is to learn more about your attitudes and choices surrounding birth control and contraceptive methods. As you may recall, you participated in the Teen Health Empowerment Study through a series of surveys, the first one occurred at the health clinic where you sought services. These discussions are a separate aspect of the study to collect further information with young women from the study in the Minneapolis area.

Your participation is voluntary and there are no negative consequences should you choose not to participate. You may choose not to participate in any aspect of the conversation if you do not feel comfortable. All of the information provided during these discussions will be kept confidential by the study team, and only members of our study team will have access to the information you share. Neither your name nor the names of your colleagues who participate will be reported, and the notes we take about our discussions will not be shared with or provided to the federal government or anyone else except the members of the evaluation team. During the discussion, we will take notes, but none of the responses will be attributed to any individual, rather they will be collected as a group and summarized. There is some risk that information shared during this discussion could be repeated outside of the group. Prior to the discussion, we will remind all participants not to disclose anything that they learn. The discussion will be about 90 minutes.

If you have any further questions that we may not be able to answer about this study or this discussion, please contact Dr. Meredith Kelsey, the Abt Associates Project Director at 617.520.2422 or via email at THEstudy@abtassoc.com. If you have any questions about your rights, please contact Ms. Katie Speanburg by phone at 877.520.6835 [toll free number].

By signing this form, I agree to take part in this small group discussion being held in my community.

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Your Signature Print Your Name Date

Consent for Discussion with Health Educators

As you know, Abt Associates is conducting the federal Teen Health Empowerment Study. As an important part of that effort, we would like to talk with program staff in an effort to understand and document the process of replicating an evidence-based model (SSI) in real-world settings, the challenges that arise, and how staff on the ground respond to those challenges. The information we gather will serve two purposes:

1. help future program operators and policymakers understand what is needed to replicate a program with fidelity, to implement it as intended, with the populations originally targeted; and

2. help us understand variations in program impacts, where they occur.

Your participation is voluntary and there are no negative consequences should you choose not to participate. You may choose not to discuss any topic or end the discussion at any time. The information we collect now will be used to help us understand your program and the process of replicating SSI. It will help to provide important insights into the infrastructure required to support a strong implementation of the program. Neither your name nor the names of any of your colleagues who participate will be reported, and the notes we take about our discussions will not be shared with or provided to the federal government or anyone else except the members of the evaluation team.

By signing this form, I agree to take part in this small group discussion with health educators.

_________________________ __________________________ _______________

Your Signature Your Name Date