Adolescent Consent

“Evaluating a HIV/AIDS Focused Video Game for Young People”

Generic Information Collection request under 0920-0840

(exp. 02/29/2016)

Attachment 2b. Adolescent Assent

Flesch-Kincaid Grade Level 6.5

Centers for Disease and Control Prevention

Youth Assent to be in a Research Study

Thank you for your interest in this research study. Before you decide whether to agree to be in this study, please read this form along with me as I read it aloud and ask as many questions as you need to be sure you know what you will be asked to do.

Introduction: This study is being done by researchers from the Centers for Disease Control and Prevention.

What is the purpose of this study? The goal of this study is to test an HIV/AIDS educational video game designed to teach people your age about HIV/AIDS and Sexually Transmitted Infections (STI) prevention for youth ages 11 and 17. This study is important because young people are at higher risk to get HIV/AIDS.

Why am I being asked to be in this study? We are asking you to be in this study because you are a youth (11-17).

What is going to happen during the study?

You will finish 2-3 surveys and possibly play an HIV/AIDS prevention video game. You will be chosen to play the game based on the race, sex of participants where you were recruited. If you are not chosen to play the game during the study, you can play it after the study is over. You will be asked to answer questions about HIV/AIDS, and sexual behaviors. We will ask you questions about the video game if you played it. If you play the game you will take 2 surveys the day the study begins. You will take another survey 30 days after you finish the first survey. If you do not play the game, you will take a survey the day they begin the study and second one 30 days after.

What do you want me to do if I decide to be in this study? We would like you to take surveys and possibly play a HIV/AIDS prevention video game. We would like you to answer the questions in the survey. On the survey, you will be asked questions about HIV/AIDS knowledge, their sexual behaviors and what you think about the video game if you play it.

How long will you need me? How long we need you depends on if you are chosen to play the game. If you are chosen to play the game, we will need you for up 60 minutes. If you are not chosen to play the game we will need you for 30 minutes.

If you are selected to play the game, we expect it will take up to 45 minutes to take 2 surveys and play the game. 30 days after playing the game you will take a survey. It should take you 15 minutes to finish this survey. If you don’t play the game, minutes on the day you begin the study you will take 1 survey. It should take 15minutes to finish it. . You will take another 30 days after taking the first survey.

Are there any risks to me if I decide to be in this study? There is low risk to you if you decide to be in this study. Since we may a lot of sensitive questions during the survey, you may feel uneasy. You do not have to respond to any questions you do not want to the survey.

Are there any benefits from being in this study? By being in this study you may be able to dispel myths about HIV/AIDS and STI. You will also help us design a video game that will help prevent HIV/AIDS and STI.

Will the things I tell you be kept private? What you tell us will be kept private to the extent allowed by law. The things you tell us in the survey will be kept secure by the research staff. We will not tell anyone you finished a survey about the study. If we think there may be child abuse or that you cause harm to yourself or others, we will report this concern to the proper authorities.

Will you share information with parents/guardian?

The researcher does not plan to share your answers with your parent(s). However, the overall, findings of the study will be shared with parents, if requested. If this makes you uneasy, you can chose not to participate in the study. You will be not be forced to answer any questions. You may elect to quit the study if they become are uncomfortable at any time.

What will you do with the answers to the surveys? Answers to the surveys will be used to write papers on what we have found. We will share our findings with the people working on the study. These people will review the study reports and survey answers to help us understand what we have found. We also hope to make public our findings in a journal magazine, so that we can share what we found with other people. At no time, will anyone know what you said or that you were in this study. We will also share our findings with you if you would like. You may also have a copy of any of the reports.

Is there any cost if I take part in this study? The only cost to you for being in this study is your time for coming here today.

Is there any reimbursement if I take part in this study? There is no reimbursement for taking part in this study, but you will receive a token of appreciation of $10 if they participate finish the 2 surveys and/or play the video game and an additional $15 if you finish the 30 day follow up survey.

Who should I call if I have questions about this study or think I may have been harmed by this study? If you have any questions about this study you or your parent/guardian may call Dr. Leigh Willis, MPH, 404-639-8447. If you have questions about your rights for being in this study, you may call the CDC Institutional Review Board at 1- 800-584-8814.

Do I have to be in this study? You do not have to be in this study, it is up to you if you want to or not. You can stop being in this study at any time without being in any trouble.

Do you have any further questions about this study?

Please print and sign your name below if you agree to be in this study.. By signing your name you also agree that you have read this form and have had a chance to ask any questions you may have about the study. You will be given a copy of this consent form for you to take with you.

________________________________________

(Youth) Print your Name Date

(Youth) Sign your Name Date

Will you allow us to keep your contact information so we can provide you the general results of the study? Circle yes or no.

Yes No (Please do not contact me again)

I observed the process of consent. The prospective participant read or was read this form, was given the chance to ask questions, appeared to accept the answers, and signed to enroll in the study.

Signature of Research Staff Date