Attachment 9: 9-11 IRB

ATTACHMENT 9

Child Interview Assent 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 Assent Form

CHILDREN AGES 9 to 11

I, understand that my parents (mom and dad)/guardian have/has given permission (said it’s okay) for me to take part in a project done by Gallup.

I am taking part because I want to.  I understand that what I say will only be heard by the people doing the interview and they will not tell my parents (mom and dad)/guardian what I told them.

I have been told that I can stop at any time I want to and nothing will happen to me if I want to stop. I also know that if I stop during the interview I will still get the gift card that was promised to me.

Child’s Signature

_______________________________

Principal Investigator's Signature and Date

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

Interview Assent Form for 9-11 Year Old ChildrenPage 1