Att_B.1_Adult_consent_form

Attachment B.1

Adult Consent Form

RIViR Study

RIViR Study

Consent Form for Adults

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 consent 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 people 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 decide to participate, you will be asked a series of interview questions about romantic relationships, including experiences with unhealthy relationship behaviors and violence. The questions will ask about your personal experiences with romantic or intimate partners, like boyfriends, girlfriends, husbands, or wives. You will also receive written information about domestic violence and healthy relationships and be asked some questions after receiving it. A [PROGRAM NAME] staff member will ask you these questions in person. There will be three different interviews at three different times over the course of about 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 determine whether to offer you any additional services. In addition, RTI will receive information on your age, race and ethnicity, and other personal characteristics collected by [PROGRAM NAME].

VOLUNTARY PARTICIPATION

Your decision to take part in this research study is completely voluntary. You do not have to agree to participate in order to get services from [PROGRAM NAME] or anywhere else. If you participate in the study, you can skip any questions or leave the study at any time. You can also choose not to participate in all three interviews.

STUDY DURATION

Two of the interviews will take about 10 minutes each to complete, and another 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 interview, you may ask the interviewer to take a break or to skip any of the questions. The other risk is that someone might find out what you tell us during the interviews. In order to avoid that, we will do the interview in a private setting where no one can overhear the answers. 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 adults who participate in healthy marriage and relationship education programs.

TOKEN OF APPRECIATION

You will receive a $5 gift card after answering each set of interview questions and an additional $5 gift card if you complete all three interviews 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, for example, your spouse or partner, will be able to find out what you said in the interviews. Your name will be replaced with a number for the purposes of this study. The project staff will not share your information with anyone outside the study, except with your permission (for example, for us to refer you to [DOMESTIC VIOLENCE PROGRAM PARTNER]). There are two other exceptions: 1) If you tell us that someone’s life or health could be in danger, and 2) if you tell us that a child is being abused or neglected. 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] have 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 participate in two more interviews, over the course of the next 2 months. We will also ask for your contact information after the first interview so that an RTI staff member may contact you separately to ask for your feedback on this project.

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 or your rights as a study participant, 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.

________________________________________ __________ Participant’s Signature Date

________________________________________ __________

Printed Name of Participant Date

________________________________________ __________

Signature of Person Obtaining Consent Date

________________________________________ __________

Printed Name of Person Obtaining Consent Date

COMPLETE AND RETURN THIS PAGE. KEEP THE REST OF THIS CONSENT 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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