Attachment D Youth Assent

ATTACHMENT D

 YOUTH OUTCOME SURVEY ASSENT FORM  

Form approved

OMB Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

STATEMENT OF ASSENT

SURVEY – for youth under 18

REAL Essentials Advance study

Sponsored by the United States Department of Health and Human Services

An adult has described the REAL Essentials Advance study to me, and any questions I had were answered. I was told that I have been selected to be a part of the study and that my parent or guardian has agreed to my participation. I understand I will be asked to complete up to three surveys and that each survey will take about 40 minutes to complete. All my information will be kept private to the extent allowed by law. However, if I say that I am going to hurt myself or someone else, or that someone is hurting me, someone on the study team will take steps to make sure that I am safe. My personal information will not otherwise be given to anyone outside of the study or shown to my parents or guardians. In the future, data collected through the surveys may be securely shared with qualified individuals for additional learning purposes to better understand adolescent health programming. The information that is shared will only include a study ID number and not my name.

I also understand that I do not have to answer any questions that make me feel uncomfortable.

[ONLY FOR STUDENT ENGAGEMENT PILOT DISTRICTS: I was also told my class may be video/audiotaped to learn more about student interest and engagement in the REA curriculum. This audio/video will only be used for the purposes of research (e.g., analysis of responses, and transcriptions of responses) and will not be available to anyone aside from the research team and their partners. If I don’t want to be recorded, I will be placed in an area of the room that that is designed to be excluded from the video and audio recording.

I agree to be recorded if my classroom is included in the student engagement study:

Yes No ]

If I have questions about the study, I can call:

• Melissa Thomas, Survey Director at Mathematica, toll-free at 1-800-XXX-XXXX

• If I have questions about my rights as a research volunteer, I can call Health Media Lab Institutional Review Board (HML), toll-free at 1-800-XXX-XXXX.

I understand that participation is voluntary, and I agree to participate in the survey. I understand that I am allowed to stop participating in the survey at any time, without punishment.

Please sign and complete the information below if you agree to complete the survey. We will use your contact information only to try and reach you to complete an additional survey.

____________________________ ______________________________________________

Name Signature Date

Email:

Cell phone: ( ) _________ - ______________

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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.

______________________________________

Melissa Thomas

Survey Director

Signature Date: 01/30/2021