Attachment E4 SC Child Assent age 9-18 3-13-07

Attachment E4: South Carolina Assent age 9-18

South Carolina PLAY
Project to Learn about ADHD in Youth

SC PLAY ASSENT FORM for RESEARCH

(For 9-19 Year Old Participants)

Your parent has said that it is okay for us to talk to you about a study of children that the University of South Carolina is doing. The study is about attention, hyperactivity and impulsive problems and how these affect kids and their families. We want to find out about the thoughts, feelings and behaviors of children your age. We would like for you to help us by answering some questions about these subjects. We will also be asking your parent and teachers about these things.

If you would like to participate, we will ask you to do two different tasks:

First, we will begin with a computer interview: You will wear headphones so only you can hear the questions and see what you answer. Second, we will also ask you to fill out some questionnaires. We will ask you some sensitive questions about tobacco and alcohol. If you are 11 or older, some of the questions will be about drug use and rule breaking, if you are 14 or older, we will also ask about sex. The answer sheets will not have your name on them, only a code number. No one else needs to see what you answer.

It will take about two hours or a little more to do all of these things, but you can take some breaks if you want to. You do not have to be in this study; it is your choice. It will not affect how you are treated at school or anywhere else if you say no. If you do decide to help us with our study, we will give you a $25 gift card after we finish the interview today; even if you do not answer all the questions. You don’t have to answer any questions if you don’t want to, and you may stop anytime just by telling us that you do not want to continue. We will talk to you and to your parent separately so you can’t hear what each other are saying. We will keep your answers private, but we will talk to your parents if you report serious problems, like having been hurt by someone.

Do you have any questions? Is this OK with you? If this is OK with you, please sign your name below. You will get a copy of this to keep.

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Sign Your Name Date

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ADHD Staff or Investigator Date

Study Principal Investigator: Robert E. McKeown, PhD

Dept. of Epidemiology & Biostatistics · Arnold School of Public Health · Columbia, SC 29208

Phone: (803) 777-1124 · Fax: (803) 777-2524

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