Parental Permission Form

Parental Permission and Informed Consent

The National Survey on Drug Use and Health (NSDUH) is a large survey given to about 70,000 people across the country every year. RTI International conducts the NSDUH. It collects information on many health-related issues. Right now we’re testing some new questions about past drug and alcohol use to learn how well people understand these questions and how they might go about answering them. We are under contract with the Substance Abuse and Mental Health Services Administration to carry out this survey. You or your child responded to an advertisement that we placed for research subjects. At present, we are seeking the help of young people like your child to see how our new questions work.

Your child is one of 12 adolescent respondents in Washington, DC, Chicago, IL, Portland, OR, and Research Triangle Park, NC who are participating in this study. Taking part in the interview is strictly voluntary. Your child can skip any portion of the interview he/she does not wish to be involved with. There is no penalty if he/she chooses to skip any part of the interview. The interview will be conducted in private to ensure nobody else overhears his/her answers. All answers will be kept private and confidential. We will not share the information given to us with any person outside the project staff, and your child's name will never be connected to the answers he/she provides. Federal law requires us to keep your child’s answers confidential and to use his/her answers only for statistical purposes (the Confidential Information Protection and Statistical Efficiency Act of 2002). The only exception to this promise of confidentiality is if your child tells me that (he/she) intends to seriously harm him/herself or someone else or if (he/she) tells me (he/she) has been abused, or if your child identifies a person who has given (him/her) drugs. In this situation I may need to notify a mental health professional or other authorities.

The interview will take about one hour. During the interview, your child will be asked survey questions about past drug and alcohol use. The survey includes questions about the use of alcohol and drugs such as marijuana. In addition to these questions, we will ask follow up items about the survey questions to determine how your child decided on an answer for these questions and if they were clear and easy for your child to understand. For example, we may ask your child to repeat the question in his or her own words.

(He/She) will receive $40 in cash in appreciation for the interview.

We would like to audio record the interactions between your child and the interviewer. The recording will be heard only by members of the research team to help us make sure we have all the information from your child about how these questions work. To protect (his/her) privacy, the recording will remain on the laptop computer, which will be protected by a password. The recording will be destroyed soon after the study ends. However, having the interactions recorded is voluntary and you can decline for your child.

[Read only if observer is present: Members of the RTI research team or representatives of SAMHSA are here with us today and would like to observe this interview from a separate observation room. If you do not want anyone else to observe your interview, we will simply ask these people to leave the observation room and then do the interview.]

If you have any questions about this study, you can contact Emily Geisen at RTI at 1-800-334-8571 X. 26566). If you have any questions about your rights as a parent or legal guardian or your child's rights as a study participant, you can call RTI's Office of Research Protection at 1-866-214-2043 (a toll-free number).

Do we have your permission for [CHILD’S NAME] to participate?

As Parent/Guardian, I give my permission for my child to participate in this interview.

____Yes ____No

As Parent/Guardian, I give my permission for my child’s interview to be audio recorded:

____Yes ____No

As Parent/Guardian, I give my permission for members of the RTI research team or representative of SAMHSA to observe the interview:

____Yes ____No

Signature of Interviewer: ______________________________

Date: __________________

NOTICE: Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930-0290); Room 2-1057; 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0290, expiration date 5/31/17.