Attachment 8: Parental Consent Form

ATTACHMENT 8

Parent Consent Form

OMB No. 0930-0196

Expiration Date: 09/30/2013

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0196. Public reporting burden for this collection of information is estimated to average 45 minutes per respondent per year, including time for responding to questions, reviewing message concepts provided, and sharing reactions and ideas within the group. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.

One-on-One, In-depth Interview Parental/Guardian Consent Form

This is to certify that I,________________________________, hereby agree to allow my

(Parent or Guardian’s Name)

child _____________________________ to participate in this project being conducted by the Gallup Organization.

I understand the information given to me about the project and my child’s part in it have been fully explained to me and I have received answers to any questions I may have had about the process.

I understand that my child will be part of an interview process where he/she will be asked to share opinions with a moderator.

I understand that my child is free to decline to answer specific questions or items in the interview.

I understand that any data or answers to questions will not be shared with me.

I further understand that I am free to withdraw my consent and terminate my child’s participation at any time.

___________________________________________

Parent/Guardian Signature and Date

I certify that the informed consent procedure has been followed and that I have answered any questions from the participant as fully as possible.

__________________________________________________

Principal Investigator's Signature and Date

For additional information contact: Lamont Rooker, Gallup Organization at 202-715-3064