PPA OMB Package - Appendix F - Consent Form - 9-8-08

APPENDIX F

ASSENT/CONSENT FORM

FOR FOCUS GROUP PARTICIPANTS

Exploration of Pregnancy Prevention Approaches

CONSENT/ASSENT FORM FOR FOCUS GROUP PARTICIPANTS

REQUIREMENTS FOR PARTICIPATION IN FOCUS GROUP

In order to participate in the focus group, this form must be reviewed and signed. If the participant is a minor (i.e. under 18 years of age) or is a high school student, the form must be signed by both the participant and the parent/guardian. Consent/assent for the audio recording of the focus group (see last part of form) is not required for participation in focus group.

PREGNANCY PREVENTION APPROACHES

The federal government is funding a study evaluating different approaches to preventing teen pregnancy – including abstinence and safer sex. [FILL IN NAME OF CONTRACTOR] is conducting this evaluation.

SELECTION OF FOCUS GROUP PARTICIPANTS

You/your child are/is involved in a program which has a specific approach to preventing teen pregnancy. One of the program’s staff has nominated you/your child to participate in a focus group with other participants, to tell us about the program.

DESCRIPTION OF FOCUS GROUP

The focus group is likely to last around 90 minutes. The focus group will include members of your/your child’s peers. The focus group format will be an informal discussion led by a facilitator. Questions will focus on what types of activities occur in the program, what kind of content is included/excluded in the program, and what kinds of outcomes have occurred because of the program. For example, one of the questions is open-ended, asking what kinds of things are discussed in the program. As another example, one of the questions relates to whether you/your child has made any personal decisions because of the program. Answers to all questions are completely voluntary.

PURPOSE OF FOCUS GROUP

The purpose of the focus group is to find out more about the program in which you/your child is involved, specifically about how participants in the program (i.e. you/your child) perceive the program and its outcomes.

VOLUNTARY PARTICIPATION

Your/your child’s participation in this focus group is completely voluntary. If you/your child don’t/doesn’t want to participate, that is okay. If you/your child don’t/doesn’t want to answer a certain question, that is also okay. Your/your child’s refusal will not affect any benefits that you may be receiving, including participation in the current program or (if appropriate) grades in the current class. You/your child have/has the right to take a break from, or leave, the focus group at any time.

RISKS

There are no physical risks to you/your child from participating in the focus group. It is possible that some questions might make you/your child uncomfortable or feel various emotions.

BENEFITS

There are no direct benefits to you/your child from answering the focus group questions. However, you/your child will be helping us learn more about programs geared toward preventing teen pregnancy, and ultimately about what types of programs may be effective.

CONFIDENTIALITY

Beyond this consent form, no identifying information will be collected from you/your child; and during the focus group, your/your child’s answers will not be connected with any identifying information. No one will see your/your child’s answers to any of these questions. Your/your child’s name will not be reported with any information you provide. Information you/your child provide(s) will be combined with answers of many others and reported in a summary form. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge.

Your answers will be kept confidential to the greatest extent allowable by law. However, if the interviewer or project staff feel that anyone’s life or health is in serious danger, they will inform the appropriate county or state agency.

QUESTIONS

If you have any questions about the study, you may call [ENTER CONTRACTOR INFORMATION].

You will be given a copy of this consent form to keep.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is [ENTER INFORMATION]. The time required to complete the focus group is estimated to be 90 minutes.

The above information has been explained to me, and my signature below indicates that I give consent for me/my child to participate in the focus group.

Printed Name of Participant		Signature of Participant		Date
Printed Name of Parent/Guardian (if participant is minor or high school student)		Signature of Parent/Guardian		Date

We will be making audio recordings of the focus group is all participants (and parents/guardians) consent. The recordings will be reviewed by project staff at [CONTRACTOR’S NAME AND SITE]. The recordings will only be used for review, and will be kept confidential. The files will be destroyed after they have been reviewed. Project staff who listen to the recording will know who I am, but will not know who you are. Is it alright with you if this focus group is audio-recorded? If you indicate no, you will still be able to participate in the focus group, and the focus group will not be audio-recorded.

Check one box.

	Yes, I consent to having the focus group audio-recorded.
	No, I do not want any portion of the focus group to be recorded.

Printed Name of Participant		Signature of Participant		Date
Printed Name of Parent/Guardian (if participant is minor or high school student)		Signature of Parent/Guardian		Date