Appendix C Example of AB Grantee Program Consent 5 1 12

Form Approved

OMB No. 0990-NEW

Expiration date xx/xx/20xx

Dear parent/guardian,

Your son/daughter has the chance to participate in an exciting and fun program to help youth learn about their health. Touchstone Behavioral Health will be starting their Teen Pregnancy Prevention Program (TPPP) at _______________. The purpose of the program is to help youth behave in ways that will support good health and protect them from unwanted pregnancy or developing serious health problems like sexually transmitted infections (STIs) including HIV/AIDS. It has been used with hundreds of youth in the United States and Mexico and has been proven to be effective in helping reduce their risky sexual behavior. As a parent, you can help support your child in staying healthy by allowing him/her to participate in the program.

During the program your child will be involved in a variety of learning experiences, including small group discussions, films/videos, games, exercises, and role-playing designed to teach youth about different health problems- including teen pregnancy and sexually transmitted infections including HIV/AIDS and how they can be avoided through abstinence or birth control, including a condom demonstration (please note that condoms are not distributed for youth to take home). Your child will be learning important information in a supportive, fun, and informative program.

You are welcome to review the contents of the program and the teaching materials before the program starts. Please contact Sonia Ruiz, Prevention Assistant, at 602-732-4950 to set up a time to view the materials. If you have questions about the program or need additional information please call Erica Chavez, Prevention Coordinator, at 602-732-4950.

The Teen Pregnancy Prevention Program also offers intervention services. The intervention services are available if TPPP or the site’s staff believes a youth is at high risk or needs additional services. Then the youth will be referred to a Touchstone Behavioral Health Interventionist who will meet with your youth to discuss his or her needs and refer them to the necessary services. We are committed to preserving the privacy and confidentiality of your child’s health information. We will only contact parents if the youth requests us to; or if the youth is in danger, is a danger to his or her self, or is a danger to others. We are required by state and federal regulations to abide by the privacy practices and release information in cases of medical emergency, abuse or neglect, court order, and where otherwise legally required. Otherwise, the youth will be seen in a confidential manner unless you wish to see the notes on the service, which you may request.

I have read and understand the information given above. I have been given the opportunity to ask questions and review program materials. My questions have been answered to my satisfaction. Upon signing below, I understand that one copy of this document will be kept together with your records.

Child’s name: ______________________________Parent/Guardian’s name:_______________________________

Please choose one option below for your child’s participation:

______ I agree to have my son/daughter participate in the Teen Pregnancy Prevention Program and the intervention program (if deemed necessary)

______ I agree to allow my son/daughter to participate in the Teen Pregnancy Prevention Program ONLY (not the intervention portion)

Parent/Guardian’s Signature: ____________________________________ Date: ____________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

EVALUATION CONSENT FORM

During the first and last sessions of the Teen Pregnancy Prevention Program (TPPP), youth participants will be asked to fill out a questionnaire which collects information on their knowledge of HIV/AIDS and other sexually transmitted infections (STIs) as well as their intentions regarding sexual activity or abstinence. It will also ask general background questions (e.g., student’s race or ethnicity, gender and age), but no personally identifying information will be recorded on the questionnaires. A copy of the questionnaire(s) is available upon request for you to review. Filling out the questionnaire will take about 15 minutes. Your child’s participation is completely voluntary and your teen is free to skip (i.e., not answer) any question they want.

In addition to the pre- and post-program questionnaires, a follow-up evaluation study will take place six months after your child has completed the Teen Pregnancy Prevention Program. The follow-up study will ask students to reflect back on the past 6-months to again answer questions related to their knowledge of HIV/AIDS and other sexually transmitted infections (STIs) as well as their history regarding sexual activity or abstinence. Incentives will be provided to all youth/families who participate in the 6-month follow-up study in the form of $10 gift certificates to merchants located in the Maryvale community. The incentive will be provided upon your adolescent’s completion of the survey.

All of the information your child provides to project staff is private to the extent possible by law. No one other than the TPPP project staff will know what your child’s answers are on questionnaires. Your youth will not be asked to put your name or any other personally identifying information on the questionnaire. Should you choose to include identifying information, we will destroy your name, address, and phone number as soon as they are no longer needed.

Participation is completely voluntary and you or your child may withdraw from participation in Touchstone’s Teenage Pregnancy Prevention Program at any time. Any information you have provided before withdrawing will not be used in the study or for any other purpose. It will be destroyed along with all other data when the study is complete.

If you have questions or concerns, please contact the Coordinator of Touchstone’s Teenage Pregnancy Prevention Project, Erica Chavez, at (602) 732-4950.

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The study described above has been explained to me. I volunteer my son and/or daughter to take part in this evaluation of the Teen Pregnancy Prevention Program. I have had a chance to ask questions. I understand that one copy of this document will be kept together with your records.

Child’s Name:________________________________________

______________________________________________________________________ __________________

Signature of Parent/Guardian Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer