National Survey of Youth in Custody (NSYC)

National Survey of Youth in Custody – Parent/Guardian Consent Form

RE: ______________________________________________ OMB NO.: 1121-0303

Name of Youth EXPIRATION DATE: 08/31/2008

The U.S. Department of Justice is doing a special study called the National Survey of Youth in Custody to learn more about what it is like for young people living in correctional facilities. The government will use the study to see if changes there needs to be made at changes in facilities. All the answers that youth at the facility give will be combined into one report about the facility. No names will appear in the report.

Young people in every state in the country will be asked to be part of this study and we would like your permission to ask your child to be in the study. If you (and your child) agree, he/she will spend about 30 minutes answering questions using a computer. Youth will be asked questions about what it is like living at the facility, including questions about the staff, other youth who live in the facility, and the health services he/she might have used. Some youth will also be asked questions about alcohol and drug use, and some will be asked about sexual experiences that might have happened, including those in this facility.

The computer will randomly decide which questions your child is asked; it has nothing to do with your child’s background or history. If your child agrees to be in the study, a researcher will show him/her how to use the computer. He/she will see the questions on the screen and hear the questions through headphones. Your child will touch the screen to answer the questions. No one will know which questions your child is asked or what he/she answers.

Your child does not have to do the survey. It is entirely up to you whether we can ask your child, and then it is up to your child. Your choice will not affect your child’s case or the services that he/she gets in any way. If your child agrees to do the survey, he/she can stop answering questions at any point. If there is a question that your child does not want to answer, he/she can skip it.

We will do everything we can to protect your child’s privacy. To help keep everything private:

• The researcher who meets with your child, We will not ask for your child’s name and your child he/she will not be asked to put their his/her name in the computer.

• All the answers that he/she puts in the computer will be confidential – that is, no one will know your child’s answers.

• All of the researchers working on this study have signed a legal certificate guaranteeing stating that they will protect your child’s privacy and promising not to tell anyone anything that he/she has said.

• But there is one important exception to the privacy rule. If your child tells the researcher about any abuse or harm to him/her or anyone elseanother child, it will be reported to the government agency that investigates these kinds of problems.

Some of the questions on the computer might ask about private and sensitive things and may bother your child. If thinking about the questions upsets or makes your child sad, he/she may want to talk with a counselor at the facility. If he/she does not want to talk to a counselor who works there, arrangements can be made to talk with a counselor who does not work at the facility or for him/her to call the ChildHelp National Hotline.

If you have any questions about the study, you can call the facility or you can call CONTACT at 1-800-937-8281. CONTACT works at Westat, the research firm conducting this study for the Department of Justice. If you have questions about your child’s rights as a study participant, you can call IRB CONTACT at the same telephone number1-800-937-8281.

Please indicate your choice by checking one of the boxes below and signing and dating the form. Then return it in the enclosed self-addressed stamped envelope.

Yes, I give my permission for you to ask my child to take part in this study.

No, I do not give you permission to ask my child to take part in this study.

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Your signature Date

PGC-021408