American Indian/Alaska Native Campaign: Focus Group Study of Reactions to Strategic Concepts Designed to Prevent Youth Tobacco Use

OMB# 0910-0796
Exp. 6/30/2018

American Indian/Alaska Native Campaign: Focus Group Study of Reactions to Strategic Concepts Designed to Prevent Youth Tobacco Use

YOUTH ASSENT TO PARTICIPATE IN RESEARCH

1. My name is (identify yourself by name to the child).

2. We are asking you to take part in a research study because we are trying to learn more about kids and smoking. Based on what we learn from you, we will make up positive messages and images. We want to create messages to help kids not smoke. Then we will make changes based on the advice and ideas you share with us.

3. If you agree to be in this research project, you will be talking in a group with other kids. It’s called a focus group. We’ll first do a game to get to know each other. Then, two people will ask you questions. We want to learn what you think and feel about smoking. We hope you will discuss your ideas with other youth. The focus group will last two hours.

4. There is a small risk that things that are private to you could get out. This is not very likely. We will not keep anything that shows who said what. When we use information in a report, the report will not say names. There is also a risk that after the group other group members might talk about what was said in the group. Before we start the group, everyone has to agree that they will not talk to others about who said what during the meeting.

5. We will tape record and take notes about what was said. We will not write down who said what. We will not tell your parent or caregiver what you said, and won’t tell anyone else involved in your life. We will not keep anything that shows who said what. When we use information in a report, the report will not say any names.

6. There is no direct benefit to you. What you say will help us learn more about kids and smoking.

7. Please talk this over with your parents before you decide whether or not to participate. We will also ask your parents to give their permission by signing this form for you to take part in this study. But even if both of your parents say “yes” you can still decide not to be in this study.

8. If you don’t want to be in this study, you do not have to participate. Remember, being in this study is up to you and no one will be upset if you don’t want to participate or even if you change your mind later and want to stop.

9. You can ask any questions that you have about this study. If you have a question later that you didn’t think of now, you can call me at (###) ###-#### or ask me the next time you see me.

10. Signing your name below means that you agree to be in this study. You and your parents will be given a copy of this form after you sign it.

________________________________________ ________________________________

Name of Participant Date

Caregiver’s Statement

I have read and understand the preceding information and agree to participant’s participation in the focus group.

Caregiver/Guardian/Parent’s Signature Date

________________________________________ ________________________________

Signature of Investigator Date

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete the Youth Assent Form (the time estimated to read, review, and complete). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to [email protected].