Attachment E

Attachment E

Sample of PARENT Letter and
Parent Statement of Consent Form

Important note: The eight different survey sites may modify the Sample Parent Letter that explains the study as well as the Sample Statement of Consent in order to meet the requirements of their local Institutional Review Boards (IRBs). ACF will provide these documents as models of the most basic content that should be included in the letter and Consent Form that the sites will submit to their IRBs.

SAMPLE PARENT LETTER

EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES (PPA)

(Sponsored by the United States Department of Health and Human Services)

Dear Parent or Guardian:

The Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (DHHS) is interested in finding out what works best to reduce teen pregnancy and sexually transmitted infections. The Evaluation of Adolescent Pregnancy Prevention Approaches will provide scientific evidence about effective programs, and help educators, parents, and community groups make decisions about how to help teenagers avoid risky behaviors. We are requesting permission for your child to participate in the study.

The [school/program] is taking part in this important study and your child, along with other students in [his or her class/the community], has been selected to participate. As part of the study, Mathematica Policy Research will collect information on the school performance, attitudes, and activities of the youth in the study. They will do surveys of participants several times over the next few years. These surveys will ask about families, friends, communities, and schools. They will include questions about activities in school and with friends, as well as attitudes, knowledge, and behaviors, including sexual activity, drug use, and alcohol use. The study team will also gather information from your child’s school records, including grades, attendance, and test scores.

All of the information collected through the surveys with your child and from his/her school records will be kept strictly private. The information will be combined with information from other participants in the study, and no one will ever see the answers your child gives on the survey. Names are not kept with the answers to the survey.

Participation in the study is voluntary. You or your child can refuse to participate in the study. If you agree that your child can participate, you or your child can still choose at a later time or date to stop participating, and your child can decide to complete only parts of the surveys. But we hope you agree with us that it is important to learn about how we can effectively help youth deal safely with the pressures they face in the world. It is important that you let us know whether or not you will allow your child to take part in the study. Please complete the attached form and return it to [place] no later than [date]. [Statement about incentives to parent/class/program or school, as appropriate.]

The enclosed brochure may answer some questions you have about the study. If you have any questions about the Pregnancy Prevention Approaches (PPA) evaluation or about your child’s participation, please call [contact], the school coordinator, at [number] or call me, toll-free, at Mathematica Policy Research at 800-[number] between the hours of 9 a.m. and 5 p.m. Eastern Daylight Time, Monday through Friday.

Sincerely,

[Name]

Study Director

SAMPLE STATEMENT OF CONSENT

EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES (PPA)

(Sponsored by the United States Department of Health and Human Services)

I have read the attached information sheet describing the study. By signing this form, I am

_____ giving my permission /____ not giving permission for my son or daughter, _______________________, to participate in the study. I understand that, as part of the study, information for all study youth will be collected from school records and through surveys. By signing this form, I am giving my permission for information to be gathered from my son/daughter’s school records for use in a study that will be conducted by a research firm, Mathematica Policy Research, Inc. I understand that I may decide later that my child should stop participating in the surveys at any time, and my child can decide that also. I understand that my child may refuse to complete the surveys or parts of them. I further understand that all information on my child will be kept private and used only for the purposes of the study.

Parent/Guardian

Signature ______________________________________ Date ___________________

Please fill in the following information. We will use your contact information only if we need your help in completing a survey with your child. Thank you.

Parent/Guardian Name: _______________________________________________

Street Address _____________________________ Apartment # ____________

City ___________________________ ZIP________________

Child’s Name: ___________________ Child’s date of birth:____ / ______ / _____ Month Day Year

Parent/Guardian Contact Information

Telephone (_____) ____ - ___________ Home

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Email: _________________________

WE NEED YOUR ANSWER, WHETHER IT IS YES OR NO.

PLEASE RETURN THIS FORM TO [PLACE] BY [DATE]

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