Attachment G Interview Consent Seed revised-clean

OMB Control #0970-0356, Expiration Date 01/31/2015

Attachment G: Interview Consent - Seed

COLLEGE OF ARTS AND SCIENCES
Department of Sociology

201 Benton Hall
P.O. Box 880623
Lincoln, NE 68588-0623
(402) 472-5562
FAX: (402) 472-4983
Toll Free: 1-888-567-5285

SOP Data Collection Project [Personal Interview]
University of Nebraska-Lincoln
Les Whitbeck, Principal Investigator
201 Benton Hall
Lincoln, NE 68588-0623
Phone: 402-472-5562
Fax: 402-472-4983

E-mail: [email protected]

PARTICIPANT INFORMED CONSENT FORM
This study is sponsored by money from the Family and Youth Services Bureau and is being conducted by
__________ in cooperation with the University of Nebraska-Lincoln. The goal of this study is to find out
how we can best help runaway and homeless young people. We want to know what kind of experiences
homeless young people have had. We will use this information to identify the services that will best help
young people who do not have a regular place to live. If you are between the ages of 14 and 21 and don’t
have a regular place to live right now, we would like to ask you to be part of our study. Whether you say yes
or no will not make any differences in the services you can get from any service agency.
If you want to participate in this study we will want to interview you. The interview will take 1.0 – 1.5 hours.
You will receive a $20 gift card for finishing the interview. You will also be given three coupons to hand out
to other homeless or runaway young people you know. We will reimburse you with a $10 gift card for each
person who turns in a coupon you gave them and completes an interview by
/
/
. You can pick up these $10 recruitment gift cards at the agency at least two weeks after
your scheduled interview.
During the interview someone will ask you questions and enter your answers into a computer. You will be
asked questions about your family, where you have been staying, why you left home, and what has
happened to you since you haven’t had a regular place to live. You will also be asked about things like
your feelings, your daily activities, and how your life is going. Some questions are about sensitive topics,
like drugs, sex, and gang activity. You may refuse to answer any questions that make you uncomfortable.
Some of the questions may bring back bad memories or make you feel sad.. You can stop the interview
any time you want, but you won’t receive the
$20 gift card unless you participate in most of the interview (at least 30 minutes) and any information collected
before you stop the interview can still be used.

Privacy
Everything you tell me will be private. The people who see your answers will not know your name, they will
only see an ID number. Any forms you sign, like this consent form, will be kept in a locked file away from your
interview answers. The only people who will have access to both your name and answers will be UNL staff.
Although the information you provide will be private, there are three things that the interviewer is required to tell
someone else about, including your caretaker and/or public agencies.
1. Any case of suspected physical or sexual abuse and/or neglect of children must be reported to Child
Protective Services. This may be yourself or a sibling or someone you know that you tell us about.
2. If you tell me you are going to hurt yourself badly, or I think you might try to kill yourself, I will
get help for you. If the researchers have very serious concerns, they will need to report the
situation to the appropriate authorities.
2. If you say that you are aware of serious harm that may be done to someone else, the interviewer is
required to take steps to protect that person, which includes reporting the situation to the
appropriate authorities.
Risks and Benefits
Some questions may be sensitive or bring up bad memories. In order to minimize risks:: 1) The most sensitive
questions will be given in a self-administered questionnaire which you will complete directly on the computer,
2) you may refuse to answer the question or choose to end the interview at any time,, , 3) If you feel upset during
or after a session, let me know and I will contact a staff person at the agency to help you. The benefits from
participating in this study are: 1) You will be providing important information that will help agencies develop
and sustain programming specific to homeless youths’ needs, 2) You will be able to share your life experiences
with the interviewers, 3) You will be able to provide information regarding the unique needs of homeless youth
in your community, 4) Interviewers will provide you with an information card for services available in the area.
Contact Information
This study is completely voluntary. You decide whether or not you would like to be involved. You may ask
any questions concerning this research & have those questions answered before agreeing to participate or at
anytime. If you have any additional questions of concerns, you may call the principal investigator, Les
Whitbeck, at (888) 567-5285. If you have questions about your participation in this study that have not been
answered by this individual, or to report any concerns, you may contact the UNL Institutional Review Board,
at (402) 472-6965.
Interview Informed Consent
SOP Data Collection Project
Your signature on this form indicates the following:
I agree to participate in the SOP Homeless Youth Project.
I understand that I will receive a $20 gift card for completing the personal interview and a $10 gift
card for each person (up to three) who turns in a coupon I gave them and completes an interview
by
/
/
.
I understand that all information I provide will remain private.
I understand that participation is voluntary and I may stop the interview at any time.
I understand that if I stop the interview, the services I may be receiving will not be affected.
I know that if I have any questions about this study I can talk with someone at the agency where I
was interviewed and they will answer my questions.
I agree to the study’s purpose and my involvement.
I do not give up any of my legal rights by signing this form.

If you are not sure you understand everything we just read, I will be happy to answer any questions you have
now, or I can give you some time to talk to agency staff before you decide. Please feel free to ask me any
questions about the study before you sign the consent. You will be given a copy of this consent form to keep.

Participant’s Printed Name

Date

Participant’s Signature
I was present when this was read and I think that he/she understood everything and has agreed to participate
in the study.
Staff Signature

Date