Attachment D
Parental Consent
Permission for Minor Child to be in a Research Study
Purpose: The Centers for Disease Control and Prevention (CDC) through the Office of Adolescent Health is sponsoring an evaluation of programs that are funded to reduce teen pregnancy by educating young people on issues such as responsible behavior, relationships, and youth development. The purpose of this study is to learn more about risk behaviors of youth between the ages of 15-19 years old so that improvements can be made to teenage pregnancy prevention programs. Please ask questions if there is anything about the study you do not understand.
We are seeking permission for your child to participate in this study in order that we may learn more about risky behavior among youth, including beliefs, values, and social norms. Your child will be asked questions around family relationships, their community, friends, alcohol and drug use, and sexual activity. The interview will be conducted on a laptop computer and will take approximately 45 minutes.
Risks and Benefits: There are no direct benefits to your child for being a part of this project. Your child may feel uncomfortable when answering questions about personal matters. We have taken steps to protect their privacy.
Compensation: If you agree to participate in this project, your child will receive $20 for the interview to help with costs associated with participating in the project. Participation in this interview is voluntary, and your child will be compensated even if he or she does not complete the interview.
Protection of Information: The information your child gives us will be kept private to the extent allowed by law. All the information collected during this study will be kept as secure as possible by the individual field interviewers who conduct the interviews. The information is transferred to secure computer systems at the study headquarters. The information provided by the youth will not be shared outside the project; the youth’s name will not appear on any documents. Their responses will be presented as a group with other youth who participate.
There are some times when we cannot promise to keep your child’s name secret. If they tell the person who interviews them that he/she plans to hurt themselves or someone else, then the interviewer will have to tell a doctor or some other authority so that the child may get help. Interviewers must obey State laws and report certain kinds of diseases that other people can catch and they must report child abuse.
Participant Rights: You are not obligated to participate in this study. If you agree to allow the youth to participate, you or the youth have the right to change your mind and withdraw at any time without penalty or loss of benefits to which you are otherwise entitled.
Contact Information: If you have any questions about this evaluation project, you can call Chad Rodi, ICF International to have your questions answered. You can call him collect at 404.321.3211. If you have any questions about your child’s rights as a research volunteer, please contact CDC/ATSDR’s Acting Deputy Associate Director for Science at 1-800-584-8814. Leave a message with your name, phone number, and refer to CDC protocol # ____, and someone will call you back.
Voluntary Consent: I read this form, or it has been read to me, and I understand what it says. My questions (if any) have been answered. I agree that my child____________________ has my permission to participate in this study.
Parent/Guardian Signature __________________________________
Date____________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Informed Consent – Caregiver |
| Author | Gordon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |