Youth Assent Materials

Attachment 4
Youth Assent Materials

Table of Contents
I.

Youth Assent Script ............................................................................................ 3

II.

Youth Assent Form ............................................................................................. 5

OMB NO.:
EXPIRATION DATE:

U-S # _____________________

SYC Youth Assent Form
We are doing a special study for the U.S. Department of Justice to find out more about what it’s like for
young people living in places like this. The study is called the National Survey of Youth in Custody.

The government will use the study to see if changes need to be made at places like this. We will
combine the answers that people from this place give into a report on this facility. We will also
tell the state agency responsible for protecting youth about answers related to the safety of youth
at this place. No names will appear in the report and it won’t say anything about who said what.
We’re asking people in every state in the country to be part of this study and we would like you to be part
of the study. If you agree to be part of the study, you’ll answer some questions using this computer.
•

Answering the questions takes about 30 minutes.

•

You will be asked questions about what it is like living at the facility, including questions
about the staff, other youth who live in the facility, and some of the health services you might
have used.

•

You might be asked questions about alcohol and drug use before you came here. Or you
might be asked about sexual experiences, including those that might have happened in this
facility.

•

The computer will randomly decide which questions you are asked; it has nothing to do with
why you are at this place or what you might have told someone.

•

Answering is easy. You’ll see the questions on the screen and hear the questions in the
headphones. You touch the computer screen to answer the questions.

•

Nobody, not even me, will know which questions you get or what you answer.

•

You don’t have to do this study. It’s entirely up to you. No matter what you decide, your case
will not be affected in anyway. You can start the interview and then decide to quit at any
time. Just tell me that you want to stop and I’ll tell you what to do. If you want to skip a
question, that’s ok too.

•

Everyone working on this project is required by law to protect your privacy. Your
answers will always be kept private. I will not ask your name and you will not be asked to put
your name in the computer. No one on the project or on staff here will ever know your
answers.

•

There is one important exception to this privacy rule. If you tell me that you or anyone
else has been abused or harmed, I will report it to the government agency that investigates
these reports.

•

So again, if you answer on the computer, even if it is about being abused or harmed, no
one will know your answer, not even me. But, if you tell me directly that you or anyone

else has been abused or harmed, I will report it to the government agency that
investigates these reports.
•

If thinking about the questions upsets you or makes you sad, I can arrange for you to talk with
a counselor who works here. If you don’t want to talk to a counselor who works here, I can
arrange for you to talk with a counselor who does not work here or someone from the
ChildHelp National Hotline (1-800-4-A-Child or 1-800-422-4453). Just let me know.

If you have any questions, you can ask me anytime while I’m here. After I leave,
•

If you have any questions about your rights as a study participant, you can call Sharon Zack
at 1-800-937-8281, ext. 8828. She works for the same company that I work for.

•

If you have questions about how the study works, call the National Survey of Youth in
Custody Information Line at 1-888-XXX-XXXX (toll- free).

So that’s it. I hope that you’ll be willing to take part in this important study. No matter what experiences
you have had, your answers will help us understand what it’s like for young people in places like this.

INTRO-032007

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U-S # _____________________

OMB NO.:
EXPIRATION DATE:

INTERVIEWER NAME: ____________________________________
DATE: ___________________________________________________

AM
Time Started: __________________PM

SYC Youth Assent Script
Hello: My name is (AME). Before we get started, I’d like to ask you a few quick questions.
First, what is your date of birth? __________________________ COMPARE DATE TO STATUS
REPORT. RECONCILE, IF NEEDED.
1. Why do you think I asked to see you? IF DK GO TO Q3.

2. (IF RESPODET SAYS A “STUDY”) What do you think the study is about?

3. Are other people in this place talking about who I am and what I am doing here? (IF
YES) What are they saying?

GIVE THE YOUTH THE OFFICE COPY OF THE ASSENT FORM AND ENCOURAGE HIM/HER
TO READ ALONG WHILE YOU INTRODUCE THE STUDY.
I work for a research firm named Westat outside of Washington, DC and…We are doing a special study
for the U.S. Department of Justice to find out more about what it’s like for young people living in places
like this. The study is called the National Survey of Youth in Custody.

The government will use the study to see if changes need to be made at places like this. We will
combine the answers that people from this place give into a report on this facility. We will also
tell the state agency responsible for protecting youth about answers related to the safety of youth
at this place. No names will appear in the report and it won’t say anything about who said what.
We’re asking people in every state in the country to be part of this study and we would like you to be part
of the study. If you agree to be part of the study, you’ll answer some questions using this computer.
•

Answering the questions takes about 30 minutes.

•

You will be asked questions about what it is like living at the facility, including questions
about the staff, other youth who live in the facility, and some of the health services you might
have used.

•

You might be asked questions about alcohol and drug use before you came here. Or you
might be asked about sexual experiences, including those that might have happened in this
facility.

•

The computer will randomly decide which questions you are asked; it has nothing to do with
why you are at this place or what you might have told someone.

•

Answering is easy. You’ll see the questions on the screen and hear the questions in the
headphones. You touch the computer screen to answer the questions.

•

Nobody, not even me, will know which questions you get or what you answer.

Before I go on, let me make sure that what I’m telling you makes sense. Based on what I’ve said so far…

4. Do you think I will be asking you the questions or do you think the questions will be
asked by the computer?
The interviewer
The computer

5. Do you think I will decide which questions to ask you or do you think the computer will
decide?
The interviewer
The computer

6. Do you believe that anyone, even me, will know which questions you are asked or what
you answer?

Yes
o

PROBE AS NEEDED TO FIND OUT THE SOURCE OF ANY CONFUSION.
NEEDED.

CLARIFY AS

Ok, that’s good. Is it ok if we keep going?

•

INTRO-032007

You don’t have to do this study. It’s entirely up to you. No matter what you decide, your case
will not be affected in anyway. You can start the interview and then decide to quit at any
time. Just tell me that you want to stop and I’ll tell you what to do. If you want to skip a
question, that’s ok too.

2

7. ow, if someone asked you whether you had to do the interview or whether it was
voluntary, what would you say?
Had to do it.
I didn’t have to do it/ it was voluntary.

PROBE AS NEEDED TO FIND OUT THE SOURCE OF ANY CONFUSION.
NEEDED.

CLARIFY AS

And these paragraphs are very important.

•

Everyone working on this project is required by law to protect your privacy. Your
answers will always be kept private. I will not ask your name and you will not be asked to put
your name in the computer. No one on the project or on staff here will ever know your
answers.

•

There is one important exception to this privacy rule. If you tell me that you or anyone
else has been abused or harmed, I will report it to the government agency that investigates
these reports.

•

So again, if you answer on the computer, even if it is about being abused or harmed, no
one will know your answer, not even me. But, if you tell me directly that you or anyone
else has been abused or harmed, I will report it to the government agency that
investigates these reports.

Just so I’m absolutely sure you understand this…

8. If you tell me that you or anyone else has been abused or harmed, will I have to report it
to a government agency?

Yes
o

9. If you answer on the computer that you or anyone else has been abused or harmed, will I
have to report it to a government agency?

Yes
o

•

INTRO-032007

If thinking about the questions upsets you or makes you sad, I can arrange for you to talk with
a counselor who works here. If you don’t want to talk to a counselor who works here, I can
arrange for you to talk with a counselor who does not work here or someone from the
ChildHelp National Hotline (1-800-4-A-Child or 1-800-422-4453). Just let me know.

3

If you have any questions, you can ask me anytime while I’m here. After I leave,
•

If you have any questions about your rights as a study participant, you can call Sharon Zack
(1-800-937-8281, ext. 8828). She works for the same company that I work for.

•

If you have questions about how the study works, call the National Survey of Youth in
Custody Information Line (1-888-XXX-XXXX).

So that’s it. I hope that you’ll be willing to take part in this important study. No matter what experiences
you have had, your answers will help us understand what it’s like for young people in places like this.

IF THE YOUTH UDERSTADS THE ASSET COCEPTS, ASK FOR ASSET.
Are you willing to be part of this study?
YES
O

BEGI ACASI ITERVIEW

IF THE YOUTH UDERSTADS THE ASSET COCEPTS AD REFUSES TO PARTICIPATE,
THAK YOUTH AD CODE REFUSAL (DISPOSITIO CODE: 210).

IF YOUTH DOES OT UDERSTAD ASSET COCEPTS, ACTIVIATE ITERVIEWER SMS AD
SELECT THE FACILITY/UIT. GO TO THE “UPDATE YOUTH DISPOSITIO” SCREE, ETER
THE YOUTH ID AD SAY…
ow, I’m going to enter your number into the computer. The computer will decide what questions you
will be asked or if you will be asked any questions at all.
ETER DISPOSITIO CODE 809 AD SAY…
According to the computer, you do not have to answer anymore questions. But I really appreciate that
you took the time to help us.
COMPLETE A IRF AD DETAIL THE ISSUES.

AM
Time Ended: __________________PM

INTRO-032007

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