Adoloescent survey assent - Family and Cultural Impact

“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”

Attachment 2c. Adolescent Survey Assent

Assent Form African American Child

California State University, Dominguez Hills (CSUDH)

Assent to be in a Research Study

Thank you for your interest in this research study. Before you decide whether to agree to be in this study, please read this form and ask as many questions as you need to be sure you know what you will be asked to do.

Introduction: This research study is being done by Dr. Carl Sneed, from CSUDH and funded by the Centers for Disease Control and Prevention. In order for you to be in this study, your mom must be in the study to.

What is the purpose of this study? Based on other studies, it seems that children who feel they can talk with their parents about sex are less likely to engage in high-risk actions. The purpose of this study is to find out what your mom has told you about sex. Also we want to learn about the effects that family values and culture has had on how your mom has talked to you about sex.

Why am I being asked to be in this study? We are asking you to be in this study because you are an African American between the ages of 12 to 15 years old.

How long will you need me? You are asked to complete a survey on a computer that will take about 60-90 minutes. However, we are in the process of requesting more money to extend this study. If we are given further funding, we would like you to be part of this study for 2 years.

What is going to happen during the study? You will be asked to answer questions that deal with how you and your mom talk about sex. The program on the computer will ask you questions and you will answer the questions using a touch screen or the keyboard. Headphones will be provided to ensure privacy and no one other than the research staff will be able to see your answers. A research assistant will be in the same room with you to help you if you have any questions.

What do you want me to do if I decide to be in this study? We are asking you to complete a survey on the computer. The survey will take place either at your home or at CSUDH.

Are there any risks to me if I decide to be in this study? There is no physical risk to you if you decide to be in this study. The survey may ask a lot of private questions and you may feel uneasy or have some concerns, but you do not have to respond to any questions you do not want to.

Are there any benefits from being in this study? Things learned from this study may help researchers and other people who create programs for children improve how parents talk to their children about sex.

Will the things I tell you be kept private? The questions you answer during the survey will be kept secure by the research staff. Since you will be assigned a number, no identifying information such as your name or address will be on the survey. That is we will keep you identify and the things that you say safe and will not share it. Also, we will not tell your mom what your answers were.

Is there any cost if I take part in this study? The only cost to you for being in this study is the time it takes you to do the survey.

Is there any pay if I take part in this study? After the survey, we will give you $20 as a token of appreciation for your time with us. You will receive this token even if you do not finish the survey.

Who should I call if I have questions about this study or think I may have gotten sick or been harmed by this study? If you have any questions about this study or your rights for being in this study, you may call Dr. Carl Sneed, 310-243-3463, or the Institutional Review Board for the Protection of Human Subjects at CSUDH, 310-243-3756.

Who should I call if I have questions about my rights as a study volunteer? If you have any questions about your rights as a study volunteer, you may call the Institutional Review Board for the Protection of Human Subjects at CSUDH, 310-243-3756.

Do I have to be in this study? You do not have to be in this study, it is up to you if you want to or not. Your choice will not change your relationship with CSUDH or the Boys & Girls Club. You can stop being in this study at any time without any penalty or loss of benefits.

Do you have any further questions about this study?

Signature of Research Subject

Please print and sign your name below if you agree to be in this study. By signing your name you also agree that you have read this form and have had a chance to ask any questions you may have about the study. You will be given a copy of this consent form for you to take with you.

Print your Name

Sign your Name Date

Please initial below:

______ I agree to be contacted for future research studies.

______ I do NOT agree to be contacted for future research studies.

I observed the process of consent. The prospective participant read or was read this form, was given the chance to ask questions, appeared to accept the answers, and signed to enroll in the study.

Signature of Research Staff Date