Form #3 Form #3 Adolescent behavior and communication survey consent-ass

Post Card Consent

D

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ate: Valid for Use Through:

Study Title: Connecting Primary Care Practices with Hard-to-Reach Adolescent Populations

Principal Investigator: Stephen Ross MD

COMIRB No:

Version Date:

Version No:

Your child is being asked to be in this research study because (1) they are a patient of a practice that is adopting a screening tool to improve adolescent health and (2) they are between the ages of 12 and 18.

If your child joins the study, they will complete two surveys, one in the next couple of weeks, and another in six months. The surveys will be sent to your child in the mail, but can also be completed online. The surveys ask about risky behaviors that are common in youth. If you would like to review the survey, it is available at https://sites.google.com/site/coloradoclinicsforyouth/survey

This study is designed to learn more about whether screening tools recommended by the American Medical Association and others improve care and help adolescents live healthier lives.

The risks of the survey are minimal. The main risk would be if someone connected the answers on your child’s survey to your child. Every effort will be made to protect your child’s privacy and confidentiality by:

• Keeping the survey confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). Your child’s name, birth date, etc. will not be on the survey.

• The data will be stored on a secure system that is protected by firewalls, passwords, and other security measures.

• If the survey is completed online, the transmission will be encrypted (as it is for shopping online).

There may be other risks the researchers have not thought of.

If your child enrolls in the study, your child will receive a gift card worth $10 with the first survey and a gift card worth $20 for the second survey. This research will also help the public, by helping us better understand how helpful screening tools are in adolescent care.

This research is being paid for by the Agency for Healthcare Research and Quality.

You and your child have a choice about being in this study. Your child does not have to be in this study if he or she does not want to be.

If you have questions, you can call Doug Fernald MA at 303-724-9705. You can call and ask questions at any time.

You may have questions about your rights as someone in this study. If you have questions, you can call the COMIRB ( the responsible Institutional Review Board). Their number is (303) 724-1055.

If you and your child agree to be enrolled in the study, please complete the following and return it in the enclosed stamped envelope. Your child will then receive the first survey in the mail in the next two weeks.

Date:_________________________

Parent/guardian name:_____________________ Child’s name: ______________________

Parent/guardian signature: _________________ Child’s signature: ___________________

Street Address: ____________________________________________

City: ________________________________

State: _______________________________

Z

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to read the form and provide the requested information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

ip code: _____________________________

Postcard Consent

CF-157, Effective 4-26-2010