Appendix
A
Consent and Assent Forms
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Appendix
A.1.
Parent consent form
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Voluntary Parent/Guardian Consent for Youth to Participate in a Pretest of Youth Surveys
Pretest description and purpose
Your child is currently or may have previously participated in the [PROGRAM NAME] program at [LOCATION/ORGANIZATION]. [LOCATION/ORGANIZATION] is participating in a pretest of surveys that will be used by youth participating in programs similar to [PROGRAM NAME]. We invite your child to participate in the pretest, which involves: 1) completing two short surveys and 2) providing feedback on the survey questions during a focus group discussion. The surveys ask about their demographic characteristics, behaviors (including questions about substance use [HIGH SCHOOL AND OLDER VERSION: and sexual risk behaviors]), and their perceptions of the program and its effects on their future behaviors. We are not interested in your child’s actual survey responses, rather, we are interested in their thoughts on the questions themselves, whether they are easy to understand, whether they think others their age could easily respond to the questions, and whether there are ways to improve the questions.
Mathematica, an independent research organization, is conducting this study for the Administration for Children and Families (ACF). ACF is an agency within the U.S. Department of Health and Human Services that supports the health and well-being of people, including youth.
What will my child be asked to do?
If you give permission and your child also agrees to participate, they will be asked to complete two short surveys and to participate in a focus group discussion with other youth their age. The surveys take about 7-10 minutes to complete, and the focus group discussion will take no more than an hour.
The discussion will be led by trained Mathematica staff. The group will be held [in-person at [LOCATION]/virtually] on [DATE] at [TIME].
In the discussion, your child will be asked to provide their thoughts on the survey questions. We are not interested in their personal answers to the survey questions. Instead, we want your child’s feedback on the questions, including how easy or difficult they are to understand, and how the questions can be improved.
What are the risks and benefits to participating?
There are no known risks associated with this research. Your child might feel uncomfortable answering some of the questions on the surveys or in the group discussion. However, your child does not need to answer any questions that make them uncomfortable.
The activity is a group discussion. There is a chance others might share information from the discussion with people who did not participate. We ask all participants to respect the privacy of others in the group by not discussing specifics with others outside the group, but we cannot guarantee that will happen.
If you give permission and your child chooses to participate, they will receive a $50 electronic gift card as a thank you for providing their valuable feedback to help us improve the surveys.
How will my child’s privacy be protected?
Your child’s name will not be included on the survey, and none of the feedback they provide will be linked to them.
All information will be reported in aggregate. For example, “the majority of youth agreed this question was easy to understand.”
If all participants agree, the focus group discussion will be audio-recorded so the study team can review the recording later to make sure their notes are accurate. No one will have access to the recording except for the study team. The recording and all documents associated with the pretest will be stored in a secure location and destroyed at the end of the study.
All information will be kept private to the extent allowed by law. We are required by law to report your child’s name to authorities if your child says something that suggests they are likely to harm themselves, harm another person, or that someone is likely to harm them.
How will the information from the discussion be used?
The study team will write a memo for ACF that summarizes the findings from the focus groups. The feedback your child provides will be combined with feedback from other youth participating in the discussions and will be used to improve the questions for future surveys with youth. Your child’s name and their individual responses will never be shared with anyone outside of the study team.
Who can I contact for more information?
For more information about the study, please contact Melissa Thomas, Mathematica’s Survey Director at mthomas@mathematica-mpr.com or 609-275-2231. For questions about your child’s rights as a participant in the study, please contact Health Media Lab Institutional Review Board, who has approved this work, at (202) 246-8504.
Agreement to participate
By checking the box and signing your name below, you agree that your child may participate in the pretest by completing two short surveys and participating in a focus group discussion to gather feedback on the surveys.
If you agree, then your child will decide on their own whether to participate. They will sign their own agreement form.
Your signature below indicates that your questions have been answered and that you have read and understood the information provided above.
Your child’s participation is entirely voluntary. Even if you give permission for them to participate, you or your child can choose to stop participating at any time. There are no consequences to you or your child if you choose not to participate.
Please check the box and fill out the information below if you give permission for your child to participate:
☒ I accept the terms described above and give permission for my child to participate in the focus group session.
___________________________________________________________________________
Print Child’s Name
____________________________________ _______________________
Parent/Guardian Signature Date
Appendix
A.2.
Youth
assent form for youth under 18/Consent form for youth 18 and older
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Voluntary Youth Participation Agreement Form for a Pretest of Youth Surveys
Pretest description and purpose
[LOCATION/ORGANIZATION] is participating in a study to improve surveys. This is called a pretest. The surveys will be used with youth participating in programs like [PROGRAM NAME]. We are inviting you to participate in the pretest!
During the pretest, you will complete two short surveys. You will also participate in a small group discussion. The surveys ask about you and behavior. This includes drinking and smoking [HIGH SCHOOL AND OLDER VERSION: drinking, smoking, and sex]. The survey will also ask about your thoughts on the program and how you think the program may change the way you may act in the future. We are not interested in your answers to the survey questions. Instead, we want your thoughts on the questions. For example, we want to know how easy the questions are to understand and answer, and how the questions can be improved. We will go over your thoughts about these questions in the small group discussion.
Mathematica is doing this pretest for the Administration for Children and Families (ACF). ACF is an agency in the government. They are part of the U.S. Department of Health and Human Services. ACF supports the health and well-being of people, including youth.
What will I be asked to do?
You will be asked to complete two short surveys. You will also be asked to participate in a small group discussion with others your age.
What are the risks and benefits to participating?
There are no known risks to participating in the pretest. Some youth may find some of the survey topics uncomfortable. You do not need to answer questions if you are uncomfortable.
The pretest includes a group discussion. Participants should not share anything discussed outside of the group. However, there is a chance someone may share information with someone outside of the group.
You will get a $50 electronic gift card as a thank you for providing your valuable feedback to help us improve the surveys.
Do I have to participate?
No. You do not have to participate if you do not want to. [IF UNDER 18: Your parent has given permission for you to participate, but you can now decide for yourself whether you want to participate.] Even if you choose to participate now, you can change your mind later. If you change your mind, there will not be any consequences.
How will my privacy be protected?
Your name will not be included in any reports. None of the information you provide will be linked to you.
We will ask to audio-record the discussion to help us with our notes. No one will hear the recording except for the study team. You can decide whether or not you want to be audio-recorded at the start of the group.
The recording and any written notes will be stored in a secure location. They will be destroyed at the end of the project.
Nothing will be shared with your parents or anyone outside of the study team. However, if you say you might harm yourself, harm another person, or that someone is harming you, we are required to let someone know who can make sure you are safe.
How will the information from the discussion be used?
The feedback you and other youth share will be used to improve the survey questions. Your name and individual responses will never be shared.
Who can provide more information?
For more information about the pretest, please contact Melissa Thomas. Melissa works for Mathematica. You can reach her at mthomas@mathematica-mpr.com or 609-275-2231. For questions about your rights as a participant in the pretest, please contact Health Media Lab Institutional Review Board. Their phone number is (202) 246-8504.
Agreement to participate
Please fill out the information below:
☐ By checking this box, it means I have read the information above. It means I understand the information above. It also means I agree to participate in the pretest.
____________________________________________
Print your name
_____________________________________________ _____________________________________
Email address Cell phone
_____________________________________________ _______________________
Your Signature Date
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mathematica |
| File Modified | 0000-00-00 |
| File Created | 2025-09-19 |