Supporting Document for Children

B2-1

ATTACHMENT B-2:

SUPPORTING DOCUMENT FOR CHILDREN

B.2.1

Assent Form

B2-2

Attachment B-2.1

Assent Form

B2-3

Assent Form for Child to Participate in the PPW Cross-site Evaluation
Title of Study:
Are you willing to answer questions about your health, friends and your school? We want to know
more about how kids and parents communicate and how often kids take part in some health behaviors.
We are asking you to be in the program because your mom is receiving services here.
About the surveys. If you agree to participate, we will ask you questions about yourself, your health,
your friends, and about school. There may also be questions on using alcohol, drugs, and sexual
development and relationships with the opposite sex. The length of this study is approximately 12 to
15 months.
When you are asked these questions, you and I will be alone. However, you can request that your mom
be present or your mom can request to be present.
You don’t have to participate. Nothing will change with your treatment or change at school if you
agree to participate. Sometimes kids have said that answering the questions made them feel uneasy and
they wanted to talk with someone. You can call me or INSERT NAME OF ALTERNATE PERSON,
who other kids sometimes like to talk to. We will advise you or help you get treatment if you or we
feel you need it.
Once in awhile, some kids give answers that make me think they might be putting their health at risk
and need help. If a child reports a serious health or injury risk, I or another staff member who is an
expert in problems with teens will call them right away to discuss their answers and make a plan to
help them.
Your answers are private and secret. I am not being nosey about you. Your answers will be grouped
with all the other children who agree to participate. You, or your family, will not be identified in any
way.
There are no right or wrong answers, so please do not tell me what you think I want you to say or what
you think might be a good answer. If you don’t want to answer a question right away, I can come back
to it or you can decide not to answer that particular question(s).
You can quit answering these surveys at any time. If you want me to destroy any answers you give
me, I will. You can ask any questions that you have about this program. If you have a question later,
you can ask next time, call me at (XXX) XXX-XXXX, or email me at insert email address.
Signing here means you read this paper or someone read it to you and you want to answer these
surveys. If you don’t want to participate, you don’t have to sign. This is your decision; no one can
make you. No one will be mad if you don’t want to participate, even if you change your mind later.
Name of Evaluator (or member of the project staff _____________________________) has talked
with me and answered my questions and I agree to be in the study.

1

B2-4

________________________________________

_________________

________________________________________
Signature of parent/guardian/authorized representative when required

_________________
Date

________________________________________

_________________

Signature of child

Date

Signature of project staff

Date

This form is valid until ___________________________. (Insert Date)

2