Attachment 4b: Assent Form (Age 15-17)
PARTICIPANT ID: _____________
DATE OF INTERVIEW: _____________
Assent to Participate in a Research Study
Resilience and Transgender Youth
Purpose and Procedures: This project is funded by the Centers for Disease Control and Prevention (CDC). ICF International and CDC are doing a research study with transgender and other gender non-binary youth about the parts of their lives that help them to be strong, happy, and healthy. A research study is a way to learn more about people. If you decide that you want to be part of this study, we will invite you to take part in an interview with a member of our study team. Interviews last between 60 and 90 minutes. We will audiotape the interview to make sure we get all your words right. During the interview, we will ask you about what in your life helps you to feel strong, happy, and healthy. When you finish the interview, we will give you a $50 gift card as a token of appreciation for participating in this research study.
Risks: There are some things about this study you should know. Sometimes, the topics we talk about in the interview can bring up uncomfortable emotions. If that happens, just remember you are allowed to stop the interview at any time. If at the end of the interview, you are upset, we can also help connect you with someone to talk to about your feelings.
Benefits: Not everyone who takes part in this study will benefit. A benefit means that something good happens to you. We think some benefits might be that you enjoy sharing your stories. We also think this study will help health professionals know more about the positive parts of the life of youth like you.
Privacy: When we are finished with this study we will write a report about what was learned. This report will not include your name or any information that might let people know that you were in the study.
All the files from your interview will be kept safe. Paper copies will be kept in a locked file cabinet. Electronic files will be saved on a computer with a password and security system.
We plan to keep your de-identified study data for future research purposes. De-identified means the data will not have your name, only an ID number.
We promise to keep all your information private but if you tell us something that makes us think you will hurt yourself or someone else, or if you tell us that someone is hurting you, we may have to share that information with the correct authorities and/ or connect you with a professional who can help you.
Contact Persons: If later you have questions or concerns about this research study, please contact a member of the research team who will be happy to answer your questions:
Paula Jayne, PhD, MPH Michelle M Johns, PhD, MPH
CDC Health Scientist CDC Foundation Fellow
Email: [email protected] Email: [email protected]
Phone: (404)718-8191 Phone: (404)718-8858
If you have any questions or concerns about your rights as a research participant, please contact:
[IRB CONTACT INFORMATION INSERTED HERE]
You do not have to be in this study if you do not want to be. If at any time you decide to stop after we begin, that’s okay too. If you decide not to do the study or to stop early, you are still welcome at [CBO SITE WHERE INTERVIEW TAKES PLACE].
We will provide you with a copy of this form to have for later. We will keep a copy for the study as well.
Do you have any questions?
Do you agree to take part in this study? Please put your initials by your response.
_____ I AGREE to take part in this study.
_____ I DO NOT AGREE to take part in this study.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Michelle M Johns |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |