Community_Youth_Supporting

Attachment 12 – Community Member, Survey – Youth Supporting Docs
Document E.4: C-KABS Youth Caregiver Consent
Document E.5: C-KABS Youth Assent

Evaluation of the Native Aspirations Project
Document E.4: Community Knowledge, Awareness, and Behaviors
Youth Version Ages 11 and older (C-KABS-Y)
Caregiver Informed Consent Form
Purpose of the Study
The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States
Department of Health and Human Services is studying the Native Aspirations Project. American Indian and
Alaska Native tribes across the United States and its Territories have received funding to decrease risks
that contribute to suicide, bullying, school violence among youth and to increase factors that are linked to
the healthy and safe development of children and their families. On behalf of SAMHSA, Macro
International Inc. is asking that your child complete this Community Survey. The survey includes questions
about your child’s experiences, behaviors, attitudes, and beliefs. The survey also asks about things in your
child’s life that both help him/her grow and things that create challenges. The findings from the survey will
inform SAMHSA about the impact of the Native Aspirations program on community knowledge attitudes
and behavior.
Description of Participation
Your child was randomly selected to respond to this survey because your community, along with other
tribal communities across the country, received federal funding to prevent violence, bullying, and suicide
among Native American youth. The survey has 28 questions and should take approximately 45 minutes for
your child to complete. S/he may be asked to complete the Community Survey once per year for up to
three years.
Risks and Benefits
Completing this survey poses few, if any, risks to your child. One risk is that s/he may feel uncomfortable
answering sensitive questions about themselves and sharing personal matters. S/he may chose not
answer a question, or stop completing the survey altogether, for whatever reason. Your child’s
participation will not result in any direct benefits to them. However, your child’s input will be used to help
Native American youth, Native American communities, and the Native Aspirations program. If any
respondent says they feel like they want to hurt themselves or someone else or gets upset by taking this
survey, the researcher will refer them to a mental health professional on-site for immediate assistance.
Compensation
If you agree to your child’s participation in this evaluation, your child’s name will be placed in a lottery for
[Insert community-specific incentive].
Confidentiality
All responses will be treated confidentially. Your child’s name and answers to these questions will be kept
private. To protect your child’s privacy, we will keep the records in locked files and only study staff will be
allowed to use them. Your child’s name will not be used in any reports about this study. Only authorized
people will have access to the information you provide. The information that we report will be done in
aggregate, will not contain any identifying information and your child’s name will not be used in any
reports about this evaluation.
Native Aspirations Evaluation

C-KBAS -Youth Version_Caregiver Consent

9.4.2008

In addition, to help protect the information that your child gives us, we have obtained a Certificate of
Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate
of Confidentiality will protect the members of the research staff from being forced, even under a
subpoena, to release any information in which your child is identified. Exceptions to the Certificate of
Confidentiality are information on child abuse and neglect, or information regarding imminent danger to
your child or others, which we will report to the appropriate local and state agency. Additionally, DHHS
may see your child’s information if we are audited. Finally, the Certificate of Confidentiality does not imply
the endorsement or the disapproval of the Department of Health and Human Services.
Rights Regarding Decision to Participate
Participation in the interview is completely voluntary. Refusal to participate involves no penalty or
consequences. Your child does not have to answer questions that s/he does not want to answer. S/he may
choose to discontinue the survey at any time, for any reason. If your child changes his/her mind and quits,
all of their answers will be destroyed if that is what you and your child want.
Contact information
If you have any concerns about your child’s participation in this survey or have any questions about the
evaluation, please contact Christine Walrath at [email protected] or you may call her
collect (646-695-8154) or contact Kara Riehman at [email protected] or you may
call her collect at (404-592-2148).
Caregiver Consent
By signing my name below, I freely agree to allow my child to participate in this survey. I read this form or
it has been read to me. I understand what it says. I have been asked if I have any questions and my
questions (if any) have been answered.
Print your name_________________________ Date___________________
Signature_______________________________ Witness_________________

Native Aspirations Evaluation

C-KBAS -Youth Version_Caregiver Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document E.5: Community Knowledge, Awareness, and Behaviors
Youth Version Ages 11 and older (C-KABS-Y)
Youth Assent Form
Purpose of the Study
The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States
Department of Health and Human Services is studying the Native Aspirations Project. American Indian and
Alaska Native tribes across the United States and its Territories have received funding to decrease risks
that contribute to suicide, bullying, school violence among youth and to increase factors that are linked to
the healthy and safe development of children and their families. Macro International Inc. is working with
SAMHSA on this project, and is asking that you complete this Community Survey. The survey includes
questions about your experiences, behaviors, attitudes, and beliefs. The survey also asks about things in
your life that help you and things that create challenges. The findings from the survey will inform SAMHSA
about the impact of the Native Aspirations program on community knowledge attitudes and behavior.
Description of Participation
You were randomly selected to respond to this survey because your community, along with other tribal
communities across the country, received federal funding to prevent violence, bullying, and suicide among
Native American youth. The survey has 28 questions and should take approximately 45 minutes for you to
complete. You may be asked to complete the Community Survey once per year for up to three years.
There are no right or wrong answers to this survey. Here are some things we want you to know about the
survey prior to agreeing to participate:
Risks and Benefits
Completing this survey has few, if any, risks for you. One risk is that you may feel uncomfortable
answering sensitive questions about yourself and sharing personal matters. You may choose to not answer
any question, or stop completing the survey all together, for whatever reason. Your participation will not
have any direct benefits to you. But your answers will be used to help Native American youth, Native
American communities, and the Native Aspirations program. If anyone says they feel like they want to hurt
themselves or someone else or gets upset by taking this survey, the researcher will refer them to a mental
health professional on-site for immediate assistance.
Payment
If you agree to take part in this evaluation, you will be placed in a lottery for [Insert community-specific
incentive].
Confidentiality
All responses will be treated confidentially. Your name and answers to these questions will be kept
private. To protect your privacy, we will keep the records in locked files and only study staff will be
allowed to use them. Your name will not be used in any reports about this study. Only authorized people
will have access to the information you provide. The information that we report will be done in aggregate,
Native Aspirations Evaluation

C-KBAS -Youth Version_Youth Assent Form

9.4.2008

will not contain any identifying information and your name will not be used in any reports about this
evaluation.
In addition, to help protect the information that you give us, we have obtained a Certificate of
Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate
of Confidentiality will protect the members of the research staff from being forced, even under a
subpoena, to release any information in which you are identified. Exceptions to the Certificate of
Confidentiality are information on child abuse and neglect, or information regarding imminent danger to
you or others, which we will report to the appropriate local and state agency. Additionally, DHHS may see
your information if we are audited. Finally, the Certificate of Confidentiality does not imply the
endorsement or the disapproval of the Department of Health and Human Services.
Rights Regarding Decision to Participate
Participation in the survey is completely voluntary – you do not have to complete the survey if you don’t
want to. There is no penalty or bad consequences if you choose not to fill out the survey. You do not have
to answer questions that you do not want to answer. You may choose to stop filling out the survey at any
time, for any reason. If you change your mind and quit, all of your answers will be destroyed if that is
what you want.
Contact information
If you have any concerns about your participation in this survey or have any questions about the
evaluation, please contact Christine Walrath at [email protected] or you may call her
collect (646-695-8154) or contact Kara Riehman at [email protected] or you may
call her collect at (404-592-2148).
Voluntary Assent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree to be in the
the survey.

Youth’s Name (Type or Print Full Name): ____________________________________________________
Signature of Youth: ______________________________________ Date: ____/____/____
THANK YOU

Native Aspirations Evaluation

C-KBAS -Youth Version_Youth Assent Form

9.4.2008