Attachment C_PYP Qualitative Interview Youth Assent

OMB #: 0970-XXXX [Insert logo here]

Expiration Date: XX/XX/XXXX

STATEMENT OF ASSENT FOR [ONLINE DISCUSSIONS/INTERVIEWS]

Sponsored by the United States Department of Health and Human Services

An adult from Mathematica Policy Research has explained to me that the purpose of the [online discussions/interviews] is to learn about how youth make decisions related to sexual health, youth experiences with sexual health education, and how programs can be improved to better serve youth. The study was described to me and any questions I had were answered. I was told that my parent or guardian has agreed to my participation. I understand as part of the study, I have been asked to participate in [online discussions/interviews] about my experiences with and attitudes toward sexual health education.

I understand I will not be asked about my personal behavior in the [online discussions/interviews]. I understand the research team will keep all of the information I provide in the [online discussions/interviews] private, and they will not discuss my responses with anyone outside the study team, including my teachers or parents/guardians. I understand the study team has asked participants to keep all information discussed in the [online discussions/interviews] private, but there is a risk that other youth within the group may discuss what is said with people outside the group. I also understand that I do not have to answer any questions that make me feel uncomfortable. I understand the [online discussion/interview] will take no more than ninety minutes to complete.

If I have questions about my rights as a research volunteer or questions about the study, I can call:

• The New England Independent Review Board, toll-free at 1-800-232-9570.

• [NAME] at Mathematica Policy Research, toll-free at 1-XXX-XXX-XXXX.

I understand that participation is voluntary, and I agree to participate in the [online discussions/interviews]. I understand that I am allowed to stop participating in the study at any time, without punishment.

____________________________ ____________________________ _______________

Name Signature Date

Email: __________________________________________

Cell phone: ( __) _________ - ______________

Area code

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I certify that the staff members assigned to explain the study to participants were trained to do so in terms participants would understand.

_______________________________________

Jean Knab

Project Director

[Signature Date]

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