Attach L REV FG Youth Assent Form REV 4-13-10

Attachment L: Focus Group Youth Assent Form

Focus Group

Youth Assent Form

Focus Group Youth Assent Form

INFORMED YOUTH ASSENT

On behalf of the Centers for Disease Control and Prevention (CDC), Ogilvy Public Relations Worldwide (Ogilvy PR) is conducting research to better understand how best to communicate with youth on the topic of healthy relationships.

We are asking you to take part in a small-group discussion about this topic. The discussion will take no more than 90 minutes of your time. If you agree to participate, here are things you should know:

• Your participation in this discussion is completely voluntary. You can leave the group at any time, for any reason.

• You can choose not to answer any question, at any time.

• Your name and answers to these questions will be kept secure, which means that what you say to us will not be shared with your parents, teachers, friends, or anyone else. Your answers will only be used to inform a report based on the answers of teens we talk to from all over the country, developed by Ogilvy PR and CDC. No identifying information, such as your name, will be used.

• The discussion will be audio taped.

• Staff from CDC and Ogilvy PR may watch the discussion on closed circuit TV.

• Your participation in this discussion should pose no risks to you.

• In regards to relationships, you will be asked to share your thinking, opinions, and attitudes, as well as how you would like to get related information in the future.

• Your participation will help us do a better job communicating with youth on the topic of healthy relationships.

• You will be given $(insert amount appropriate for market) for your time. Note: We often recruit more people than we need. If you were invited to participate, but are not included in the discussion because we already have the maximum number of people, you will still be paid.

Contact Information:

If you have questions about this research, please contact Nancy Accetta at 202-729-4167.

Your signature below shows that you understand the above and agree to participate in this interview.

Please print your name ____________________________________________________

Please sign your name _____________________________________________________

Date ___________________________________________________________________

THANK YOU FOR YOUR PARTICIPATION

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