Attachment I Consent Letters and Forms

ATTACHMENT I
CONSENT LETTERS AND FORMS

Form approved

OMB Number:

Expiration Date:

Dear Parent or Guardian:

Earlier this year, you gave your permission for your child to participate in the Evaluation of the Personal Responsibility Education Program, or PREP. We thank you for allowing your child to participate in the study!

As part of the evaluation, members of the study team will be conducting a focus group discussion with youth about their experiences with the PREP program. Youth, including your child, were randomly selected to be asked to participate in the focus group. We are requesting your permission for your child to participate in the focus group discussion. During the focus group, youth will be asked to discuss their experiences and level of satisfaction with the PREP program, whether they thought the program was successful, and how it could be improved. Youth participating in focus groups will be instructed not to share their own personal behaviors with the group and to instead describe their views and experiences with the PREP program.  

If you choose to let your child participate, the information from your son/daughter will be combined with information from other youth to characterize how youth who participate in PREP view the program. Your child’s name will not be attached to the answers he or she gives, and no one outside the focus group and study team will see his or her answers. The study team will keep all information collected private to the extent possible by law. Additionally, the team will ask all participants to keep the information discussed in the focus group private; however, there is a chance other participating youth may reveal information discussed in the focus group to people who were not in the focus group.

Participation in the focus group discussion is voluntary and does not affect participation in the overall study. If you agree that your child can participate in the focus group, you or your child can choose to stop his or her participation at any time with no consequences. Your child will receive a $20.00 gift card for participating in the focus group discussion. There are no additional benefits to your child participating in the focus group.

Please let us know whether or not you will allow your child to participate in the focus group discussion 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 – Focus Group

[INSTITUTION]

Sponsored by the United States Department of Health and Human Services

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

□giving my permission □not giving permission

for my son or daughter, _____________________________________, to participate in the focus group discussion. Print child’s name

If giving permission for my child to participate in the discussion, I understand that my child will be asked about his/her experiences with the PREP program, and I agree to this information being 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 by the study team and used only for the purposes of the study. I also understand the team will instruct participants to keep the information discussed private, however there is a chance other participating youth may reveal information discussed in the focus group to people who were not in the focus group. Furthermore, I understand that agreement or refusal to participate in the focus group discussion will not affect my child’s participation in the study. If I have questions about my child’s rights as a research volunteer, I can call the New England Institutional Review Board, toll-free at 1-800-232-9570.

Parent or Guardian Signature: ____________________________ Date: _______________

Child’s Name: ________________­­­­­______________

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

Form approved

OMB Number:

Expiration Date:

Hello,

Earlier this year, you agreed to participate in the Evaluation of the Personal Responsibility Education Program, or PREP. We thank you for your participation!

As part of the evaluation, members of the study team will be conducting a focus group discussion with participants about their experiences with the PREP program. You were randomly selected to participate in focus group, and we are asking you participate in the focus group discussion. During the focus group, you will be asked to discuss your experiences and level of satisfaction with the PREP program, whether you thought the program was successful, and how it could be improved. You will not be asked about or expected to share your own personal behaviors with the group, but will be asked to describe your views and experiences with the PREP program.  

If you agree to participate, your information will be combined with information from other youth to characterize how youth who participate in PREP view the program. Your name will not be attached to the answers you provide, and no one outside the focus group and study team will see your answers. The study team will keep all information collected private to the extent possible by law. Additionally, the team will ask all participants to keep the information discussed in the focus group private; however, there is a chance other participants may reveal information discussed in the focus group to people who were not in the focus group.

Participation in the focus group discussion is voluntary and does not affect your participation in the overall study. If you agree to participate in the focus group, you can choose to stop your participation at any time with no consequences. You will receive a $20.00 gift card for participating in the focus group discussion. There are no additional benefits to your participation in the focus group.

Please let us know whether or not you will participate in the focus group discussion 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 18 or Older Consent Form – Focus Group

[INSTITUTION]

Sponsored by the United States Department of Health and Human Services

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

□agreeing □not agreeing

to participate in the focus group discussion.

If agreeing to participate, I understand I will be asked about my experiences with the PREP program, and I agree to this information being collected. Additionally, I understand that participation is voluntary and may be withdrawn at any time for any reason without penalty. I further understand all information will be kept private by the study team and used only for the purposes of the study. I also understand the study team will instruct participants to keep the information private, however there is a chance other participants may reveal information discussed in the focus group to people who were not in the focus group. Furthermore, I understand that agreement or refusal to participate in the focus group discussion will not affect my participation in the study. If I have questions about my rights as a research volunteer, I can call the New England Institutional Review Board, toll-free at 1-800-232-9570.

Signature: ____________________________ Date: _______________

Print Name: ________________­­­­­______________

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

Form approved

OMB Number:

Expiration Date:

STATEMENT OF ASSENT

FOCUS GROUP

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). The study was described to me and any questions I had were answered. I was told that my parent or guardian has agreed to my participation. I understand as part of the study, I have been asked to participate in a focus group discussion about my experiences with [INSERT PROGRAM NAME] program. I understand I will not be asked about my personal behavior in this focus group. I understand the research team will keep all of the information I provide in the focus group private, and they will not discuss my responses with anyone outside the study team, including my teachers or parents/guardians. I understand the study team has asked participants to keep all information discussed in the focus group private, but there is a risk that other youth within the focus group may discuss what is said with people outside the focus group. 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:

• The New England Institutional Review Board, toll-free at 1-800-232-9570.

• 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 focus group. 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

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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