Parental Permission Form

Attachment D

Parental Permission and Informed Consent Form

Parental Permission and Informed Consent

The National Survey on Drug Use and Health is a large survey given to about 70,000 people across the country every year. RTI International conducts the National Survey on Drug Use and Health. It collects information on many health-related issues. We ask about a lot of health issues, so that we can better help everyone in the United States. Right now we’re interested in testing some new questions on alcohol, prescription drugs and other health issues that we might be using in the study. Before we do this, we want to see how well people understand these questions and how they might go about answering them. We are under contract with the Substance Abuse and Mental Health Services Administration to carry out this survey. You or your child responded to an advertisement that we placed for research subjects. At present, we are seeking the help of young people like your child to see how our new questions work.

Your child is one of twenty adolescent respondents in Chicago, IL, Washington, DC, and Research Triangle Park, NC who are participating in this study. Taking part in the interview is strictly voluntary. Your child can skip any portion of the interview he/she does not wish to be involved with. There is no penalty if he/she chooses to skip any part of the interview. The interview will be conducted in private to ensure nobody else overhears his/her answers. All answers will be kept private and confidential. We will not share the information given to us with any person outside the project staff, and your child's name will never be connected to the answers he/she provides. Federal law requires us to keep your child’s answers confidential and to use his/her answers only for statistical purposes (the Confidential Information Protection and Statistical Efficiency Act of 2002). The only exception to this promise of confidentiality is if your child tells me that he/she intends to seriously harm him/herself or someone else or if he/she has been abused or if your child identifies a person who has given him/her drugs; in this situation I may need to notify a mental health professional or other authorities.

The interview will take about an hour and a half. During the interview, your child will enter most of his/her answers to questions about drug use and other health topics into a laptop computer. The interviewer will not see the answers to those questions. However, there will be some questions in the interview that your child will be asked to discuss with the interviewer. Specifically, we will ask additional questions about how your child answered certain questions. He/She will receive a $30 Visa gift card in appreciation for the interview. Towards the end of your child’s interview, we will ask you to help answer some additional questions on the laptop computer. This part of the interview will take about 15 minutes. Your answers to these questions will remain confidential. In addition, we would like to audio record the interactions between your child and the interviewer and between you and the interviewer. The recording will be heard only by members of the research team to help us make sure we have all the information from your child about how these questions work. To protect his/her privacy, the recording will remain on the laptop computer, which will be protected by a password. The recording will be destroyed soon after the study ends. However, having the interactions recorded is voluntary and you can decline for your child.

If you have any questions about this study, you can contact Liz Dean at RTI at 1-800-334-8571 X. 27445). If you have any questions about your rights as a parent or legal guardian or your child's rights as a study participant, you can call RTI's Office of Research Protection at 1-866-214-2043 (a toll-free number).

Do we have your permission for [CHILD’S NAME] to participate?

As Parent/Guardian, I give my permission for my child to participate in this interview.

____Yes ____No

As Parent/Guardian, I give my permission for my child’s interview to be audio recorded:

____Yes ____No

Do we have your consent to participate at the end of the interview?

____Yes ____No

Do we have your consent to audio record your part of the interview?

____Yes ____No

Signature of Interviewer:______________________________

Date:__________________