School Associated Violent Deaths Surveillance System

Attachment 10

Parental Consent Form

Consent for Release of School Information for Study of School-Associated Violent Deaths, United States.

Family Member’s Name: ___________________________________

School’s Name: ___________________________________

Introduction:

Many people are worried that more and more children and adults are being killed while they are studying or working at school. Doctors have learned a lot about why murders and suicides happen. But there is still much that we do not know. Through this study, we hope to learn more about why murders and suicide happen in schools. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and the Department of Education and the Department of Justice in Washington, DC are doing a study of murders and suicides that happen in schools. We will be collecting information on all school murders and suicides that have happened since July, 1999.

We are asking you to help in this study because someone in your family was involved in a murder or suicide that happened in a school. The project we are asking you to help us with is a research study. In this study, we are asking for your permission to let people from the school where the murder or suicide happened to talk to us about your family member.

Purpose of the Research:

In this study we want to find out how many murders and suicides happen in schools. We also want to try to find out if any of these events have things in common. If there are things that these events share, then we can try to come up with ways to prevent these murders and suicides from happening in the future.

Procedures:

If you agree to let the school talk to us about your family member, then someone from the school will be interviewed about the murder or suicide that involved your family member. We will ask someone from the school a number of questions about what happened. During this survey, we will also ask questions about the school and the people that were involved. If your family member was a student at the school, we will ask questions about your child’s grades, activities, and whether they had any problems in school. We will also ask questions about whether your child had problems at home or problems with the police. Some of the questions may concern you. You may choose that you do not want some questions to be answered. If there are things that you do not want us to ask, please tell us. This survey will take about 1 hour.

You are free to give us permission to talk to people from the school or not. If you do not give us permission, nothing bad will happen to you. You will not lose any health care services, school services, or other services that you should receive.

Risks or Discomforts:

Nothing bad will happen to you or your family if you let someone from the school where the murder or suicide happened, talk to us about your family member. As we said, some of the questions we ask are about family problems, school problems, and other problems your family member may have had. The answers to some of these questions may make you uneasy. But as we said, you can tell us if there are questions that you do not want us to ask

We understand that thinking about what happened to your family member may be hard for you. Thinking about these things may depress you, perhaps a great deal. If thinking about these things upsets you, you may need to see a doctor to help you cope.

Benefits:

There will be no direct benefit for you, your family members or for the school if you agree to help us with this study. But helping us do this study may tell us a lot about why murders and suicide happen in schools. If so, that could be good for you or someone you know in the future.

Confidentiality:

Because sensitive information will be collected on your family member, CDC applied for and received an "assurance of confidentiality " for this project under the provisions of the Public Health Service Act, Section 308(d). This means that any information that CDC has that identifies you will be used only for this study and cannot be disclosed to anyone else unless those furnishing the information give their consent.

NOTE: Participants are to be given a copy of the formal 308(d) Assurance of Confidentiality Statement

To protect your privacy and your family member’s privacy, we will keep all information under a code number instead of a name. We will keep the records in locked files and only study staff will be allowed to look at them. Names or any other facts that might point to you, your family member, your community, or the school will not appear when we allow other people to look at the results of the study.

If you agree to allow the school to release information about your family member, it will remain private. If you do not agree to allow the school to release information, it will be kept private too.

Cost/Payment:

There is no cost for helping us with this study. You will not be paid for helping with this study.

Right to Refuse or Withdraw:

As we said before, you are free to give us permission to talk to people from the school or not. If you do not give us permission, nothing bad will happen to you. You will not lose any health care services, school services, or other services that you should receive. If you decide to give us permission to talk to people from the school, you are also free to change your mind later for any reason. In that case too, you will not lose any health care services, school services, or other services that you should receive.

Persons to Contact:

If you have any questions about how the study works, contact Dr. Mark Anderson, the chief study person, at 1-800-447-4784, extension 498-0821, and leave a message. We will return your call as soon as possible.

If you have questions about your rights in the study, contact Dr. Deborah Holtzman, head of CDC’s Human Subject Office, at 1-800-584-8814 and leave a message. Your call will be returned as soon as possible.

Your Consent:

I have read this consent form. I have had my questions answered so that all parts of the study are clear to me now. I have received a copy of this consent form. I agree to let people from the school where my family member studied or worked talk to people working on the study about my family member.

 I give consent for the school where my family member studied or worked to talk about the information the school has on my family member.

______________________________________ __________________

(Parent or Legal Guardian) (Date)

 I DO NOT give consent for the school where my family member studied or worked to talk about the information the school has on my family member.

______________________________________ __________________

(Parent or Legal Guardian) (Date)

1