Consent Letters and Forms, Youth Assent Form, and Contact Information Sheet

ATTACHMENT j
CONSENT LETTERS AND FORMS, YOUTH ASSENT FORM, anD CONTACT INFORMATION SHEET

Form approved:

OMB Number:

Expiration Date:

Dear Parent or Guardian:

The Office of Adolescent Health (OAH) is part of the U.S. Department of Health and Human Services. OAH is sponsoring a study of the [PROGRAM]. Mathematica Policy Research is conducting this study for OAH. [AGENCY] is taking part in it.

The purpose of the study is to understand whether the program helps youth to complete their education, delay having another baby, and increase parenting skills. The study will compare two different versions of the program. One version has [DIFFERENT FEATURES] from the other. The version of the program your daughter will receive is based on a process that is like a coin flip.

We are asking your permission for your daughter to participate in the study. If you give permission, she will be asked to take three surveys over the next two years. One will be now, one will be in one year, and one will be in two years. These surveys ask about families, friends, communities, and schools. They also ask about attitudes, contraceptive knowledge, activities, including sexual activity, drug and alcohol use, and pregnancy history. Each survey will take about 30 minutes to complete. She will receive a $25 gift card for each survey she completes.

Participation in the study is voluntary. There are no direct benefits for participating. You or your daughter can choose to stop her participation at any time for any reason without penalty. Her program status will not change if she decides to stop. You or she can call 1-855-229-6554 to stop being in the study.

Her information will be kept private to the extent allowed by law. One risk is that her confidentiality might be lost. We have taken steps to prevent this. Another risk is that she may not want to answer some questions because they are sensitive. She can decline to answer those questions. Her information will be combined with information from other youth. Her name will not be attached to the answers she gives. No one outside the study team will see her answers. It is possible the study director might change during the study. We will tell her if that happens.

Please fill out and sign the attached form if you agree for your daughter to be in the study. Return it to [PERSON] at [AGENCY].

Please call Mathematica at 1-855-229-6554 if you have questions about the study. The number is toll-free. You or your daughter can also call the [IRB] at [NUMBER] if you have questions about your daughter’s rights as a study volunteer.

Sincerely,

Matthew Stagner, Ph.D.

Project Director

Mathematica Policy Research

EVALUATION OF THE PREGNANCY ASSISTANCE FUND PROGRAM (PAF)

Parent or Guardian Consent Form—Study

[AGENCY]

Sponsored by the United States Department of Health and Human Services

I understand the study description. By signing this form, I give my permission for my daughter to participate in this study. I understand that, as part of the study, she will complete three study surveys. One will be now, one will be in one year, and one will be in two years. Each survey will take about 30 minutes to complete. By giving permission for my daughter to be in the study, I agree that she may receive an email or text message about the follow-up surveys. My daughter’s participation is voluntary. She or I can call 1-855-229-6554 to stop being in the study. She can stop at any time for any reason without penalty. All of my daughter’s information will be kept private to the extent allowed by law. It will be used only for the study. She or I can call the [IRB] at [NUMBER] if we have questions about my daughter’s rights as a study volunteer. Parent or Guardian Signature: Date: _______________

Daughter’s Name:_________________________

Daughter’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 reaching your daughter to complete a survey. Thank you.

Name:

Street Address: Apartment:

City, State: Zip Code:

Telephone: (_____) ____ - ___________ Home Email:

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Daughter’s Cell Phone: (_____) ____ - _______ Daughter’s Email: _________________________

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 Laura Kalb toll-free at 1-855-229-6554 to obtain a copy of the questions or materials.

Form approved:

OMB Number:

Expiration Date:

Hello:

The Office of Adolescent Health (OAH) is part of the U.S. Department of Health and Human Services. OAH is sponsoring a study of the [PROGRAM]. Mathematica Policy Research is conducting this study for OAH. [AGENCY] is taking part in it.

The purpose of the study is to understand whether the program helps youth to complete their education, delay having another baby, and increase parenting skills. The study will compare two different versions of the program. One version has [DIFFERENT FEATURES] from the other. The version of the program you will receive is based on a process that is like a coin flip.

You are invited to participate in the study. You will be asked to take three surveys over the next two years. One will be now, one will be in one year, and one will be in two years. These surveys ask about families, friends, communities, and schools. They also ask about your attitudes, contraceptive knowledge, activities, including sexual activity, drug and alcohol use, and pregnancy history. Each survey will take about 30 minutes to complete. You will receive a $25 gift card for each survey you complete.

Your participation in the study is voluntary. There are no direct benefits for participating. You can stop at any time for any reason without penalty. Your program status will not change if you decide to stop. You can call 1-855-229-6554 to stop being in the study.

Your information will be kept private to the extent allowed by law. One risk is that your confidentiality might be lost. We have taken steps to prevent this. Another risk is that you may not want to answer some questions because they are sensitive. You can decline to answer those questions. Your information will be combined with information from other youth. Your name will not be attached to the answers you give. No one outside the study team will see your answers. It is possible the study director might change during the study. We will tell you if that happens.

Please fill out and sign the attached form if you agree to be in the study. Return it to [PERSON] at [AGENCY].

Please call Mathematica at 1-855-229-6554 if you have questions about the study. The number is toll-free. You can also call the [IRB] at [NUMBER] if you have questions about your rights as a study volunteer.

Sincerely,

Matthew Stagner, Ph.D.

Project Director

Mathematica Policy Research

EVALUATION OF THE PREGNANCY ASSISTANCE FUND PROGRAM (PAF)

Youth 18 or Older Consent Form—Study

[AGENCY]

Sponsored by the United States Department of Health and Human Services

I understand the study description. I agree to participate in this study. I will complete three study surveys. One will be now, one will be in one year, and one will be in two years. Each survey will take about 30 minutes to complete. I may receive an email or text message about the follow-up surveys. My participation is voluntary. I can call 1-855-229-6554 to stop being in the study. I can stop at any time for any reason without penalty. All my information will be kept private to the extent allowed by law. It will be used only for the study. I can call the [IRB] at [NUMBER] if I have questions about my rights as a study volunteer. 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. Thank you.

Name:

Street Address: Apartment:

City, State: Zip Code:

Telephone: (_____) ____ - ___________ Home Email:

(_____) ____ - ___________ Work

(_____) ____ - ___________ Cell

Form approved

OMB Number:

Expiration Date:

STATEMENT OF ASSENT

EVALUATION of the PREGNANCY ASSISTANCE FUND PROGRAM (PAF)

Sponsored by the United States Department of Health and Human Services

An adult at [AGENCY] has explained to me the Evaluation of the Pregnancy Assistance Fund (PAF). 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 that I will be asked to take three surveys over the next two years. One will be now, one will be in one year, and one will be in two years. Each survey will take about 30 minutes to complete. I may receive an email or text message about the follow-up surveys. My participation is voluntary. I can call 1-855-229-6554 to stop being in the study. I can stop at any time for any reason without penalty. All my information will be kept private to the extent allowed by law. It will be used only for the study. I can call the [IRB] at [NUMBER] if I have questions about my rights as a study volunteer.

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. Thank you.

______________________________ ____________________________________ _______________

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.

_______________________________________

Laura Kalb

Survey Director

Signature Date

Form approved:

OMB Control Number:

Expiration Date:

CONTACT INFORMATION FOR RELATIVES AND FRIENDS

INSTRUCTIONS: We would like contact information for three people who will know how to reach you in case you move and we can’t find you. Please provide the name, address, phone number, and email of three relatives or friends. We will only contact these people if we can’t find you when it is time to complete a survey. We will not tell these people anything about you or the study. We will only say we need to get in touch with you to complete a survey. We will not share the contact information with anyone outside of the study team. Please share contact information starting with the person who is most likely to know how to reach you. Please also let these people know that you shared their contact information with us.

1. CONTACT INFORMATION FOR RELATIVE OR FRIEND

First Name Middle Initial Last Name

Address Apt. No.

City State ZIP Code

How is this person related to you?  Relative  Friend  Other (Specify)

TELEPHONE: ( )- -  Home  Work  Cell

Area Code

ALTERNATE TELEPHONE: ( )- -  Home  Work  Cell

Area Code

EMAIL ADDRESS:

2. CONTACT INFORMATION FOR RELATIVE OR FRIEND

First Name Middle Initial Last Name

Address Apt. No.

City State ZIP Code

How is this person related to you?  Relative  Friend  Other (Specify)

TELEPHONE: ( )- -  Home  Work  Cell

Area Code

ALTERNATE TELEPHONE: ( ) -  Home  Work  Cell

Area Code

EMAIL ADDRESS:

Thank you for

sharing this information!

3. CONTACT INFORMATION FOR RELATIVE OR FRIEND

First Name Middle Initial Last Name

Address Apt. No.

City State ZIP Code

How is this person related to you?  Relative  Friend  Other (Specify)

TELEPHONE: ( )- -  Home  Work  Cell

Area Code

ALTERNATE TELEPHONE: ( ) -  Home  Work  Cell

Area Code

EMAIL ADDRESS: