Consent Assent Focus Group Participation

Attachment 5 –

Consent Assent for Focus Group Participation

Letter of Consent/Assent for Focus Group Participation

Signature of Parent or Guardian Required

I, the undersigned, grant my permission for STUDENT NAME to attend a focus group discussion on DATE at the FOCUS GROUP LOCATION at FOCUS GROUP LOCATION ADDRESS. This activity is the second component of the National Institute on Drug Abuse (NIDA) study to improve the message of the PEERx videos that we wrote you about, when we requested your student’s participation in the survey component of this study. The focus group discussion will be conducted by NIDA’s Contractor –Strategic Research Associates of Spokane Washington.

This focus group discussion is scheduled to last approximately 90 minutes. In appreciation for my child's time, he/she will be provided with a light meal/snacks during the discussion.

I understand that this information collection is for research purposes only, the information will be used to improve the NIDA PEERx videos. His/her information and feedback will be used in the study without any identification in the analysis and reporting, or in the record, and will be stored in our secure facilities. His/her information will not be provided to NIDA, only aggregated information from the study will be made available to NIDA . No sensitive information will be asked or discussed.

________________ __ ___ _____________ ________________

(Signature of Parent or Guardian) (Date) (Printed Name of Parent or Guardian)

Student Assent to Participate in Research Study

I, the undersigned, agree to participate in the research discussion to be held on DATE at the FOCUS GROUP LOCATION at FOCUS GROUP LOCATION ADDRESS.

I understand that this group is for research purposes only and nothing will be sold. My personal information will remain private to the extent provided by law. My feedback will not be provided to NIDA, only aggregated information from the study will be made available to NIDA.

________________ __ ___ _____________ ________________

(Signature of Student) (Date) (Printed Name of Student)

EACH PARTICIPANT MUST BRING THIS FORM TO THE GROUP TO BE ADMITTED INTO THE FOCUS GROUP DISCUSSION.

IF HE/SHE DOES NOT HAVE THIS FORM, HE/SHE WILL NOT BE ALLOWED TO PARTICIPATE.

For more information, please contact Joanne Vega at Strategic Research Associates at 509-324-6960 or [email protected].