Att_B.5_Youth_assent_form

Attachment B.5

Youth Assent Form

RIViR Study

RIViR Study

Assent Form for Youth Younger than Age 18

We are inviting you to be part of a research study with [PROGRAM NAME] as part of our involvement with the Administration for Children and Families’ Healthy Marriage and Relationship Education Program. You were chosen because you are part of [PROGRAM NAME]. This information will be used to help improve programs like ours. Before you decide whether you want to take part in this study, we ask that you read this form so that you understand what the study is about and what you will be asked to do.

PURPOSE

In this study we are testing ways to ask teens who are served by programs like [PROGRAM NAME] about their romantic relationships. This study is sponsored by the Office of Planning, Research and Evaluation within the Administration on Children and Families. It is being conducted by RTI International, a research firm in North Carolina. The study will involve up to 1200 youth and adult participants at multiple locations around the country.

PARTICIPATION IN THE STUDY

If you agree to take part, you will be asked questions three different times. The questions will be about things like your relationships with boyfriends or girlfriends or other people that you are romantic with. They will ask what your romantic relationships are like, including any complicated experiences you may have had, like violence in a relationship. You will also receive some written information about teen dating violence and healthy relationships and be asked some questions after receiving it. There will be two surveys and one interview at three different times over the course of 2 months. There are no right or wrong answers. You do not have to be in a relationship to be in the study. The answers you give will be used for RTI’s study and may also be used by [PROGRAM NAME] staff to decide whether to offer you any additional services. In addition, [PROGRAM NAME] will give RTI information on your age, race and ethnicity, and other personal characteristics.

VOLUNTARY PARTICIPATION

You don’t have to take part in the study if you don’t want to. You will not get in trouble at school or with [PROGRAM NAME] if you do not take part. If you participate in the study, you can skip any questions or end the study at any time.

STUDY DURATION

The two surveys will take about 10 minutes each to complete, and the interview will take about 15 minutes. You will be asked the first set of questions today. You will be asked another set of questions in approximately 1 month, and a third set of questions about 1 month after that.

POSSIBLE RISKS OR DISCOMFORTS

Some of the questions may seem personal or bother you. If you feel uncomfortable or upset during the surveys or interview, you may take a break or skip any of the questions. The other risk is that someone might find out your answers to the questions. To avoid that, we will do the interview in a private setting where no one can overhear the answers. We will try to make sure that no one can see your answers when you take the surveys. Also, we will handle and store all of the information you provide to us in a secure manner.

BENEFITS

There are no direct benefits to you from participating in this study. However, the study results could help service providers learn about ways to improve services. By participating, you are also helping us learn more about the kinds of services that might help other teens who participate in healthy relationship education.

TOKENS OF APPRECIATION

You will receive a $5 gift card after answering each set of interview questions as a token of appreciation.

PRIVACY

We will do our best to keep all of the answers to the interview questions private. Only the people working on the study or with [PROGRAM NAME] will be able to see your answers. No one else, including your parents, other teens in the program, or your boyfriend or girlfriend, will be able to find out what you said in the interviews. We will not allow people outside the study staff to know which answers are yours unless you give permission for this (for example, for us to refer you to [DOMESTIC VIOLENCE PARTNER]). There are two other exceptions: 1) if you tell us that someone’s life or health could be in danger or 2) if you reveal a child is being hurt or not taken care of. In either of these cases, we must report it to the authorities. This includes if you are being hurt or not taken care of, or if you a friend of yours is being hurt or not taken care of. If this happens, we may need to report to someone whose job it is to see that you and/or others are safe and protected.

We may want to share the results of the study with other people who worked on the study and the funding agency, but no names will be included. After all interviews are completed, a summary will be written that contains information from all participants. The staff doing the study will not use your name in any reports.

The Institutional Review Boards (IRB) at RTI and at [LOCAL IRB INSTITUTION] has reviewed this research. An IRB is a group of people who are responsible for making sure that the rights of participants in research are protected.

FUTURE CONTACTS

If you participate in this study, we will contact you to complete two more surveys or interviews, over the course of the next 2 months.

QUESTIONS

If you have any questions about this study, you can contact the [PROGRAM NAME] Project Director, [PROGRAM DIRECTOR], at [LOCAL NUMBER] or Tasseli McKay at RTI at (800) 334-8571 ext. 25747 (a toll-free number). If you have any questions about protecting your privacy in this study, please call [LOCAL IRB LIAISON NAME] at [LOCAL NUMBER].

RTI ID:

By signing this form, you are letting us know that you have read the information about the study and that you agree to participate and for RTI to receive information on your age, race and ethnicity collected by [PROGRAM NAME]. Signing this form will not affect your receiving services here or anywhere else. Please keep pages 1-2 for your records and return this last page to project staff.

________________________________________ __________ Youth’s Signature Date

________________________________________ __________

Printed Name of Youth Date

________________________________________ __________

Signature of Person Obtaining Assent Date

________________________________________ __________

Printed Name of Person Obtaining Assent Date

COMPLETE AND RETURN THIS PAGE. KEEP THE REST OF THIS ASSENT FORM.

NOTE: The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to test ways of asking those served by healthy marriage and relationship education programs about their 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.

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