Attachment 10: 12-15 IRB

ATTACHMENT 10

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 12 to 15

I, understand that my parents/guardian have/has given permission for me to participate in an interview concerning underage drinking being conducted by Gallup.

My participation in this project is voluntary. I understand that what I say will be kept private and that anything I say will not be shared with my parent/guardian.

I have been told that I may stop my participation in this interview at any time without penalty and loss of benefit to myself and I 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 For one-on-ones with CHILDREN 12-15 Yrs Old/Page 2