PREP PAS+Baseline - Attachment G - Consent Letters and Forms and Youth Assent Form - 6-7-12

ATTACHMENT G
CONSENT LETTERS AND FORMS AND YOUTH ASSENT FORM

Form approved

OMB Number:

Expiration Date:

Dear Parent or Guardian:

The Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (DHHS) is conducting an important study of the effectiveness of ways to reduce teen pregnancy and sexually transmitted infections (STIs). The Evaluation of the Personal Responsibility Education Program, or PREP, will provide communities like yours with sound scientific findings on program effectiveness. ACF has hired Mathematica Policy Research, Inc., an independent policy research firm, to conduct this study.

[INSERT INSTITUTION TYPE] is taking part in this study, and youth, including your child, are invited to participate. We are requesting your permission for your child to participate in the study. As part of the study, research staff from Mathematica will administer surveys to youth three times over the next two years. These surveys will ask about families, friends, communities, and schools, and about attitudes, knowledge and activities in school and with their peers, including sexual activity, drug use and alcohol use. The study team will also gather information from schools about participants’ grades, attendance, and test scores. Your child might also be invited to participate in a focus group discussion.

All information collected in the surveys will be kept private to the extent possible by law. If you choose to let your child participate, the information from your son/daughter will be combined with information from other youth to determine the effectiveness of pregnancy prevention programs. Your child’s name will not be attached to the answers he or she gives, and no one outside the study team will see his or her answers.

Participation in the study is voluntary. If you agree that your child can participate, you or your child can choose to stop his or her participation at any time with no consequences. The only risk to your child connected with the study is that he or she may be uncomfortable answering some questions in the surveys. If that happens, your child can refuse to answer those questions.

We hope you agree with us that it is important to learn about effective ways to prevent teen pregnancy and STIs through studies like this. Please let us know whether or not you will allow your child to be in the study by completing and signing the attached form and returning it to [INSERT NAME OF INSTITUTION/CONTACT PERSON] within a week.

If you have questions about the PREP study or about your child’s participation, please call Melissa Thomas, Mathematica’s Survey Director, toll-free, at 1-888-XXX-XXXX between the hours of 9 a.m. and 5 p.m. eastern time, Monday through Friday.

Sincerely,

Robert Wood, PhD

Project Director

Mathematica Policy Research

EVALUATION OF Personal Responsibility Education Program (PREP)

Parent or Guardian Consent Form

[INSTITUTION]

Sponsored by the United States Department of Health and Human Services

I have read the attached information sheet describing the study. By signing this form, I am:

□giving my permission □not giving permission

for my son or daughter, _____________________________________, to participate in the study.

Print Child’s Name

If giving permission for my child to participate, I understand that, as part of the study, information for all study youth will be collected through surveys and school records including course grades, attendance, and test scores. I also understand my child might be invited to participate in a focus group discussion. By giving permission for my child to be in the study, I agree that this information to be collected. Additionally, I understand that participation is voluntary and may be withdrawn at any time for any reason without penalty. I further understand that all information on my child will be kept private and used only for the purposes of the study. If I have questions about my child’s rights as a research volunteer, I can call [INSERT NAME] at Public/Private Ventures, toll-free at 1-800-XXX-XXXX.

Parent or Guardian Signature: _______________________________ Date: _______________

Child’s Name: ________________­­­­­___________ Child’s Date of Birth: _____ / ______ / _____ Month Day Year

Please fill in the following information. We will use your contact information only if we need your help in contacting your child to schedule a study interview. We also ask you to provide contact information for someone who would know how to reach you in the event you move and we cannot contact you. If we contact this person, we will not reveal any information about your child or the study, other than to say we need to locate your child to complete a survey. Thank you.

Parent or Guardian Name: _________________________________________________________________

Street Address: ______________________________________________ Apartment: _________________

City: _______________________________________________________ Zip Code: ___________________

Telephone: (_____) ____ - ___________ Home Email: ______________________________________

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Alternate Contact Name: ___________________________________________________________________

Street Address: _____________________________________________ Apartment: __________________

City: _____________________________________________________ Zip Code: _________________

Telephone: (_____) ____ - ___________ Home Email: __________________________________

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Parents please be aware that under the Protection of Pupil Rights Act. 20 U.S.C. Section 1232(c)(1)(A), you have the right to review a copy of the questions asked of or materials that will be used with your child. If you would like to do so, you should contact Melissa Thomas toll-free at 1-888-864-6416 to obtain a copy of the questions or materials.

WE NEED YOUR ANSWER, WHETHER IT IS YES OR NO.

PLEASE RETURN THIS FORM WITHIN A WEEK.

THANK YOU!

Form approved

OMB Number:

Expiration Date:

Hello,

The Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (DHHS) is conducting an important study of the effectiveness of ways to reduce teen pregnancy and sexually transmitted infections (STIs). The Evaluation of the Personal Responsibility Education Program, or PREP, will provide communities like yours with sound scientific findings on program effectiveness. ACF has hired Mathematica Policy Research, Inc., an independent policy research firm, to conduct this study.

[INSERT INSTITUTION TYPE] is taking part in this study, and we are inviting you to participate. As part of the study, research staff from Mathematica will ask you to take three surveys over the next two years. These surveys include questions about your friends, family, community, future goals, and also about your attitudes, knowledge and activities, including sexual activity, drug use and alcohol use. You might also be invited to participate in a focus group discussion.

All information collected will be kept private to the extent possible by law. If you choose to participate, your information will be combined with information from other youth to determine the effectiveness of pregnancy prevention programs. Your name will not be attached to the answers you give, and no one outside the study team will see your answers.

Participation in the study is voluntary. If you agree to participate, you can choose to stop participation at any time with no consequences. The only risk connected with the study is that you may be uncomfortable answering some questions in the surveys. If that happens, you can refuse to answer those questions.

We hope you agree with us that it is important to learn about effective ways to prevent teen pregnancy and STIs through studies like this. Please let us know whether or not you agree to be in the study by completing and signing the attached form and returning it to [INSERT NAME OF INSTITUTION/CONTACT PERSON ] within a week.

If you have questions about the PREP study or about your participation, please call Melissa Thomas, Mathematica’s Survey Director, toll-free, at 1-888-XXX-XXXX between the hours of 9 a.m. and 5 p.m. eastern time, Monday through Friday.

Sincerely,

Robert Wood, PhD

Project Director

Mathematica Policy Research

EVALUATION OF Personal Responsibility Education Program (PREP)

Youth Consent Form

[INSTITUTION]

Sponsored by the United States Department of Health and Human Services

I have read the attached information sheet describing the study. By signing this form, I am:

□agreeing □not agreeing

to participate in this study.

If agreeing to participate, I understand that, as part of the study, information for all study participants will be collected through surveys. I also understand I might be invited to participate in a focus group discussion. By agreeing to be in the study, I agree for this information to be collected. Additionally, I understand that participation is voluntary and may be withdrawn at any time for any reason without penalty. I further understand that all information on me will be kept private and used only for the purposes of the study. If I have questions about my rights as a research volunteer, I can call [INSERT NAME] at Public/Private Ventures, toll-free at 1-800-XXX-XXXX.

Signature: _______________________________ Date: _______________

Name: __________________________________ Date of Birth: _____ / ______ / _____ Month Day Year

If you agree to participate, please fill in the following information!

We will use your contact information only if we need to reach you to complete a survey. We also ask you to provide contact information for someone who would know how to reach you in the event you move and we are unable to contact you. If we contact this person, we will not reveal any information about you or the study, other than to say we need to get in touch with you to complete a survey. Thank you.

Name: ______________________________________________________________________________

Street Address: ______________________________________________ Apartment: ______________

City: _______________________________________________________ Zip Code: _______________

Telephone: (_____) ____ - ___________ Home Email: ____________________________________

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Alternate Contact Name: ___________________________________________

Street Address: ______________________________________________ Apartment: ___________

City: _____________________________________________________ _____ Zip Code: _____________

Telephone: (_____) ____ - ___________ Home Email: _________________________________

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

WE NEED YOUR ANSWER, WHETHER IT IS YES OR NO.

PLEASE RETURN THIS FORM WITHIN A WEEK.

THANK YOU!

Form approved

OMB Number:

Expiration Date:

STATEMENT OF ASSENT

EVALUATION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP)

Sponsored by the United States Department of Health and Human Services

An adult at _______________has explained to me the EVALUATION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP). I was told that I have been selected to be a part of the study and that my parent or guardian has agreed to my participation. The study was described to me and any questions I had were answered. I understand I will be asked to complete several surveys and that the information I provide is private and will not be provided to people outside of the study or shown to my parents. I also understand that I do not have to answer any questions that make me feel uncomfortable.

If I have questions about my rights as a research volunteer or questions about the study, I can call:

• [INSERT NAME]at the Public/Private Ventures institutional Review Board, toll-free at 1-800-XXX-XXXX

• Melissa Thomas, Survey Director at Mathematica Policy Research, toll-free at 1-888-XXX-XXXX.

I understand that participation is voluntary, and I agree to participate in the study. I understand that I am allowed to stop participating in the study at any time, without punishment.

______________________________ ____________________________________ _______________

Name Signature Date

Email: __________________________________________

Cell phone: ( ) _________ - ______________

Area code

------------------------------------------------------------------------------------------------------------------------------------------

I certify that the staff members assigned to explain the study to participants were trained to do so in terms participants would understand.

_______________________________________

Melissa Thomas

Survey Director

Signature Date