Consent Assent Survey

Attachment 6 –

Parent Consent Student Assent - Survey

[DISTRIBUTED IN INFORMATION PACKETS TO EACH STUDENT]

National Institute on Drug Abuse

Permission Form

I hereby give my consent to my child, __________________________________, to participate in National Institute on Drug Abuse (NIDA) study -- Customer Feedback Information for the NIDA PEERx Videos--, that will use a web-based survey administered during the school day. The survey will be conducted by NIDA’s Contractor, Strategic Research Associates of Spokane, Washington. The survey asks for students’ opinions of the NIDA PEERx Videos (http://teens.drugabuse.gov), a government resource for students on prescription drugs misuse. The purpose of the survey is to collect information that the National Institute on Drug Abuse will use to evaluate and improve the videos and their message.

The survey will also ask students if they are interested in participating in a focus group discussion of the videos, (to be conducted at some later time), and to provide a parent first name and home phone number for later contact. If your student is interested the Contractor will contact you for your consent and to conduct a screening process with your student for inclusion in the study.

I understand and agree that the results from the study will be aggregated in analysis by the Contractor, so there will be no identification of students in the results, and will become the property of the National Institute on Drug Abuse. I also understand that my child’s name or any other identifying information will not be used or revealed in any way, nor provided to NIDA, and that there will be no harm to my child from participation in this survey.

____________________________________________ __________________________

Name of High School City, State

__________________________________________________________________________________________

Printed Name of Parent or Guardian

_____________________________________________ ________________________

Signature of Parent or Guardian if Participant is a Minor Date

_____________________________________________

Printed Name of Minor Student

_____________________________________________ ________________________

Signature of Minor Student Date

OR, if Student 18 years of age or older

I, ___________________________, am 18 years of age and am competent to contract in my own name.

____________________________________________________________________________________

PRINTED NAME OF STUDENT Date

PLEASE RETURN THIS PERMISSION FORM TO YOUR TEACHER TO BE RETURNED BACK TO:

STRATEGIC RESEARCH ASSOCIATES, 25 W CATALDO SUITE D, SPOKANE WA 99201

[STUDENT INSTRUCTIONS AND PASSWORD / NO NAMES, THESE ARE HANDED OUT RANDOMLY TO STUDENTS BY TEACHERS ALONG WITH THE PERMISSION FORMS ABOVE - PERMISSION FORMS ARE RETURNED, AND ONLY ]

To take the survey, follow these three easy steps:

1. Be sure your parent has read and understands and has signed the permission slip, and that you have returned the permission slip to your teacher.

2. Go to www.survey.strategicresearch.net/studentsurvey.html and enter the password: PASSWORD on the screen that loads (short URL: bit.ly/lllsjsjs)

3. Provide your responses! The survey takes no longer than 15 minutes for you to complete

We hope you enjoy taking our survey. Your responses will be combined with hundreds of others from students just like you, and the information you provide will never be tied to you in any way.

If you have any questions about this research effort, or need any technical assistance, please feel free to contact Joanne Vega, the National Institute on Drug Abuse's survey consultant at (888) 554-6960 x203 or by email at [email protected]

Survey URL: www.survey.strategicresearch.net/studentsurvey.html

Password: PASSWORD

Password ID: