Appendix I. Assurances of Confidentiality and Study Descriptions Provided to Respondents
Parent/Guardian Informed Consent
Teen Assent
Teen Assent Script
Parent/Guardian Informed Consent
Title of Research: Evaluation of the Safe Dates Project
Before you decide whether you want your child to take part in this study, you need to read this Informed Consent form so that you understand what the study is about and what your child will be asked to do. This form also tells you who can be in the study, the risks and benefits of the study, how we will protect your child’s information, and who you can call if you have questions. Please call Dr. Eric Finkelstein, the researcher responsible for this study, at (800) 334-8571 ext. 8074 (a toll-free number) about anything you don’t understand before you make your decision. Your child’s school is one of 54 schools participating in the study. Your child was selected for the study because of the school and grade your child is in.
This national study, sponsored by the Centers for Disease Control and Prevention (CDC), is being conducted by RTI International, a research organization located in North Carolina. We are surveying 10,000 students to learn about youth violence, including violence between preteen and teen dating couples.
If you agree to let your child participate, he or she will be asked to complete a survey this year and next school year. Questions will ask about how your child feels about dating, communicating with a dating partner, and attitudes and behaviors related to violence, including violence between preteen and teen dating couples. Your child will be asked about dating violence that he or she may have experienced or engaged in and how he or she felt about it. Your child does not have to have dated or experienced or engaged in violence in order to participate in this study. If your child moves to another school after this year, a survey may be given to your child at the new school.
Your child may be asked to complete two additional 25 minute surveys this year. Questions will ask what your child is learning in school about how to prevent and avoid dating violence. Both surveys will be given to your child in school.
Study Duration
Each survey will take one class period.
Participating in the study will pose little risk to your child. There is a slight chance that your child may want to talk with someone after taking the surveys. Students will get information about school staff they can talk to and a list of hotline numbers they can call. In addition to the risks and discomforts listed here, there may be uncommon or previously unknown risks. You should report any problems to Dr. Eric Finkelstein at (800) 334-8571 ext. 8074 (a toll-free number).
Your Benefits
There are no direct benefits to your child from participating in this study.
Benefits for Other People
Results from the study could help improve youth violence prevention programs.
Information collected about your child will be treated confidentially. The information that is identified with your child will be used for the study and not for any other purposes. Parents, school staff, family members, and other students will not have access to this information. There is one exception. If your child tells us verbally that anyone (including your child) is in danger of immediate or potential physical harm, we must report it to the appropriate authorities. (Please note that we will not take such action for written responses to questions about past experiences, only for verbal reports about current or future danger.)
Your child’s name will not be used in any reports. Information will be used only for research purposes by researchers who have signed a confidentiality agreement.
The Institutional Review Board (IRB) at RTI has reviewed this research. An IRB is a group of people who are responsible for assuring that the rights of participants in research are protected. The IRB may review the records of your child’s participation in this research to assure that proper procedures were followed. A representative of the IRB may contact you for information about your child’s experience with this research. This representative will be given your name, but will not be given any of your child’s confidential study data. If you wish, you may refuse to answer any questions this person may ask.
Someone from the study team may contact you in the future about whether you want your child to participate in another research study. If you are contacted, you will be fully informed about the new study. You will be asked whether you want your child to participate at that time.
Your Rights
Parents may review the surveys in the principal’s office before they are administered and before signing this consent form. The surveys will be available for review each year.
You may decline to have your child participate. In order for your child to participate in the study, BOTH you and your child must agree to participation. Your decision for your child to take part in this research study is completely voluntary. Students will be told that participation is voluntary. Even if you give permission, your child may decline to participate at any time. Students will also be told that they can choose to skip any questions.
Parents may withdraw their consent at any time by contacting the school principal. No action will be taken against the school, you, or your child if your child does not participate in the study.
Your Questions
If you have any questions about your child’s rights as a study participant, you may call RTI’s Office of Research Protection at 1-866-214-2043 (a toll-free number). If you have any questions about this study, please contact Dr. Eric Finkelstein at RTI at (800) 334-8571 ext. 8074 (a toll-free number). By agreeing to participate in this research, your child is not giving up any of his or her legal rights.
COMPLETE AND RETURN THIS FORM TO THE SCHOOL.
Please read the information below and check one box. Please sign and return this consent form to the school by __________.
[PLEASE PRINT] Child's name: ___________________________________
I have read this form and understand it.
[ ] I GIVE PERMISSION for my child to take part in surveys for this study.
[ ] I DO NOT GIVE PERMISSION for my child to take part in surveys for this study.
[PLEASE PRINT] Parent/Guardian name: ___________________________________
Parent/Guardian signature: ___________________________________
Date: ___________________________________
KEEP THE FIRST THREE PAGES OF THIS CONSENT FORM.
Please provide your contact information below in case we need to reach you about the study.
[PLEASE PRINT] Child's name: ____________________________________
Parent/Guardian name: ____________________________________
Mailing Address: ____________________________________
____________________________________
____________________________________
Email Address: ____________________________________
Home Phone #: (_____)_____________________________
Cell Phone #: (_____)_____________________________
Work Phone #: (_____)_____________________________
Are there two people who will always know how to contact you should your contact information change?
[PLEASE PRINT] Name: ___________________________________
Mailing Address: ___________________________________
___________________________________
___________________________________
Email Address: ____________________________________
Home Phone #: (_____)_____________________________
Cell Phone #: (_____)_____________________________
Work Phone #: (_____)_____________________________
Name: ___________________________________
Mailing Address: ___________________________________
___________________________________
___________________________________
Email Address: ____________________________________
Home Phone #: (_____)_____________________________
Cell Phone #: (_____)_____________________________
Work Phone #: (_____)_____________________________
There is a possibility that the Centers for Disease Control and Prevention (CDC) may conduct other research studies in the future with participants from the current study. These future studies will be conducted either by RTI or by another research company. If RTI is not involved, RTI would like to provide your contact information to the other research company so that they can contact you and your child about the new study. If you are contacted, you will be fully informed about the new study and asked whether you want your child to participate in the new study at that time. You may refuse to participate in any future study without penalty. If you agree, RTI will only provide your contact information to authorized research companies who agree to keep this information confidential. Your information will not be released to any company unless the new research study is approved by an Institutional Review Board (IRB). The IRB is a group that assures that studies meet the federal requirements for protection of human subjects in research.
Please read the information below and check one box. Please sign and return this form to the school.
[PLEASE PRINT] Child's name: ____________________________________
I have read this form and understand it.
[ ] I GIVE PERMISSION for someone to contact me for another research study.
[ ] I DO NOT GIVE PERMISSION for someone to contact me for another research study.
[PLEASE PRINT] Parent/Guardian name: ___________________________________
Parent/Guardian signature: ___________________________________
Date: ___________________________________
Teen Assent
Title of Research: Evaluation of the Safe Dates Project
Before you decide whether you want to take part in this study, you need to read this Assent form so you understand what the study is about and what you will be asked to do. This form also tells you who can be in the study, the risks and benefits of the study, how we will protect your information, and who you can call if you have questions. Please call Dr. Eric Finkelstein, the researcher responsible for this study, at (800) 334-8571 ext. 8074 (a toll-free number) about anything you don’t understand before you make your decision. Your school is one of 54 schools being invited to participate in the study. You were selected for the study because of the school and grade you are in.
This national study, sponsored by the Centers for Disease Control and Prevention (CDC), is being conducted by RTI International, a research organization located in North Carolina. We are surveying 10,000 students to learn about youth violence, including violence between preteen and teen dating couples.
If you agree to participate, you will be asked to complete a survey this year and next school year. Questions will ask about how you feel about dating, communicating with a dating partner, and attitudes and behaviors related to violence, including violence between preteen and teen dating couples. You will be asked about dating violence that you may have experienced or engaged in and how you felt about it. You do not have to have dated or experienced or engaged in violence in order to take part in this study. If you move to another school after this year, a survey may be given to you at the new school.
You may be asked to complete two additional 25 minute surveys this year and next school year. Questions will ask what you are learning in school about how to prevent and avoid dating violence. Both surveys will be given to you in school.
Study Duration
Each survey will take one class period.
Participating in the study will pose little risk to you. There is a slight chance that you may want to talk with someone after taking the surveys. You will get information about school staff you can talk to and a list of hotline numbers you can call. In addition to the risks and discomforts listed here, there may be uncommon or previously unknown risks. You should report any problems to Dr. Eric Finkelstein at (800) 334-8571 ext. 8074 (a toll-free number).
Your Benefits
There are no direct benefits to you from participating in this study.
Benefits for Other People
Results from the study could help improve youth violence prevention programs.
Information collected about you will be treated confidentially. Parents, school staff, family members, and other students will not have access to this information. There is one exception. If you tell us verbally that anyone (including yourself) is in danger of being hurt now or in the future, we must report it to the appropriate authorities. (Please note that we will not take such action for your written responses to questions about past experiences. We will only take action if you tell us verbally about current or future danger.)
Your name will not be used in any reports. Information will be used only for research purposes by researchers who have signed a confidentiality agreement.
The Institutional Review Board (IRB) at RTI has reviewed this research. An IRB is a group of people who are responsible for making sure that the rights of participants in research are protected. The IRB may review the records of your participation in this research to make sure that proper procedures were followed. A representative of the IRB may contact you for information about your experience with this research. This representative will be given your name but will not be given any of your confidential study data. If you wish, you may refuse to answer any questions this person may ask.
Future Contacts
Someone from the study team may contact you in the future about whether you want to participate in another research study. If you are contacted, you will be fully informed about the new study. You will be asked whether you want to participate at that time.
Your Rights
Your decision to take part in this research study is your choice. In order for you to participate in the study, BOTH you and your parent/guardian must agree to participation. Even if your parent gives permission for you to participate, you may refuse to participate at any time. If you do agree to participate in the study, you can skip any questions. No action will be taken against the school, you, or your parent if you do not participate in the study.
Your Questions
If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protection at 1-866-214-2043 (a toll-free number). If you have any questions about this study, you can contact Dr. Eric Finkelstein at RTI at (800) 334-8571 ext. 8074 (a toll-free number).
By signing this assent form, you are letting us know that you have read the study information, had your questions answered, and freely decided to try this survey.
__________________________
______
Teen’s
Signature Date
___________________________ ______ ___________________________ _____
Signature of Survey Administrator Date Printed Name of Survey Administrator Date
COMPLETE AND RETURN THE BOTTOM OF THIS FORM TO THE SURVEY ADMINISTRATOR. KEEP THE REST OF THIS ASSENT FORM.
We’re inviting you to be in a research study about youth violence, including violence between preteen and teen dating couples. There is a toll-free phone number on the form for Dr. Finkelstein, who leads the study at RTI International in North Carolina, who you can call with any questions.
This study is being conducted by RTI for the federal government. We are surveying 10,000 students. You were selected for the study because of the school and grade you are in.
As part of this study, your classroom may be observed to learn about your teacher’s violence prevention curriculum delivery and the number of students in the class. We want to learn what teachers are covering. The observer will not record any names or other personal information about you. The observer will not ask you any questions or speak during the class time.
If you agree, we will ask you to complete two surveys, one now and one next year. The questions are about how you feel about dating, talking with a dating partner, and your thoughts and actions related to violence, including violence between preteen and teen dating couples. (Some questions will ask about dating violence that may have happened to you or that you may have done to someone else and how you felt about it.) You do not have to have dated, had any violence happen to you, or done anything violent to someone else in order to take part in this study. If you move to another school after this year, a survey may be given to you at your new school.
We also may ask you to complete two more surveys this year. The questions are about what you have learned about preventing and avoiding dating violence in school.
It will take one class period to complete each survey.
Taking part in the study will pose little risk to you. There is a slight chance that you may want to talk with someone after taking the surveys. At the end of this class period, I will give you information about school staff you can talk to and a list of hotline numbers you can call.
The study results won’t help you directly but could help improve youth violence prevention programs.
All of your answers are confidential. Since the survey covers private topics, we will not let anyone outside the study, including your parents, know your answers except if the law makes us. There is one reason we would have to do this—if you tell us that anyone (including yourself) is in danger of being hurt now or in the future, we must report it. We will not do this for your written answers to questions about past experiences, only if you tell us verbally about current or future danger. Your name will not be used in any reports.
There is a group of people at RTI who have reviewed our confidentiality procedures. This group might review our records about your taking the survey, may be given your name (but not your answers), and may contact you to ask you about how things went, but you don’t have to answer any of their questions if you don’t want to. It’s up to you.
It is possible that someone from the study team may contact you in the future about whether you want to take part in another research study. If you are contacted, you will be told about the new study and asked whether you want to take part at that time.
Being in this study is completely your choice. Your parent has already said that it is okay for you to be in the study. If you do try the survey, you can skip any questions or you can stop at any time.
So if you sign the last page of this form, you are saying you’ve read the form, got all your questions answered, and are deciding to try the survey. Please tear the last page of the form with your signature, and pass that page in. You may keep the rest of the form, which explains everything I’ve just told you.
Does anyone have any questions before we start? |
| File Type | application/msword |
| File Title | Appendix A |
| Author | Kathryn LeTourneau |
| Last Modified By | FMC7 |
| File Modified | 2007-06-15 |
| File Created | 2007-06-15 |