Appendix C. Youth Focus Group Assent Forms
Assent to Participate
You are being asked to take a survey. This survey will ask you questions about yourself, your family, and your behavior. Some questions are about sexual health. These questions will be about romantic relationships, pregnancy, and sexually transmitted infections. The survey takes 30-40 minutes to finish.
Your parent or guardian signed a form saying it is okay with them for you to take this survey. But it is your choice. You will not get in trouble if you do not take this survey. Even if you say yes now, you can quit at any time. You can also skip any questions you do not want to answer.
Benefits to You
This survey will help us learn what people your age think, feel, and do. There is no personal benefit to you. Taking this survey may not make your life better.
Risks of Taking this Survey
This survey asks questions that may make you feel uncomfortable. You may also feel embarrassed or upset. We can help you find a trusted adult to talk to about how you feel. You can also call or text any adults you know and trust. At the bottom of this page, we show some names of people and their phone numbers. You can talk to them about any of the questions or how we will use your answers.
How We Will Protect Your Information
We will protect your information. We will keep all information we get about you and from you private. Only study team members will see this information. Your information will be stored in a safe data system that only the study team can see. We will not share your information with your parents or guardians or with anybody else outside of the study team. The only time this rule will change is if you tell us that you or someone else is in danger. Then we have to tell someone whose job it is to keep you and others safe.
The survey questions will not ask for your name or address. We will use a special number instead of your name. Nobody will be able to know your answers to the survey questions. When the study is over, the study team will erase your name, birthdate, and address from our records. The rest of your information will be what is called “de-identified.” This means it cannot be linked to you anymore. We may use this de-identified information for our future studies or publications. We will also share the de-identified data with the U.S. Department of Health and Human Services. When we use or share your de-identified data, it will be combined with other people’s data. This also helps to make sure that no one will be able to know your answers to the survey questions.
Who to Contact If You Have Questions
If you have questions about the survey or your participation, please talk to <<insert name>> at <<insert phone number>>. You can also call the MITRE Institutional Review Board at <<insert phone number>> if you have questions about your rights as a study participant.
Participating in this survey is your choice. Do you agree to take the survey? Choose one option below.
I will take the survey.
I DO NOT want to take the survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kriz, Sarah |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |