Atmt VV Parent Program Participant Consent Form

Attachment VV:

Parent Program Participant Consent Form

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Parent/Guardian Consent Form

What am I being asked to do?

We are asking you to participate in a research study – conducted by the Centers for Disease Control and Prevention - about middle school students and their parents/guardians. We’re interested in learning about what teenagers do, what they think about things, and their relationships with other people, including people they date or hang out with. We’re interested in learning more about how parents/guardians parent teenagers and manage their own relationships. The purpose of this study is to help us learn more about these things and help us know how different programs in your community and your child’s school are working.

You were selected to participate in this study because your child is currently enrolled at [insert middle school name].

What will I be doing?

We are asking you to fill out surveys about things you do, what you think about things, and your relationships with other people. This survey should take 30-40 minutes to complete. We will do the surveys two times a year, at the beginning and end of the school year, while your child is in the 6^th, 7^th, and 8^th grade.

Who will see my answers?

Your answers and any information we get from your school are confidential. That means that your answers and information are totally private. Your children, spouse, and child’s teachers will never see your answers. Only the researcher will see your answers. After the researcher leaves here, they’ll store your answers with a code instead of your name, so after that they won’t know whose answers are whose. We have something called a “Certificate of Confidentiality.” That means that even if your spouse or partner or anyone else demanded to see your answers, we would say no and be protected by law.

The only exception to this is if you tell us that you are planning to hurt yourself or someone else. Then we will have to tell someone so we can get help.

What if I don’t know the answers?

Some of the questions may be about things you’ve never thought about before. Some of the questions may seem like they don’t apply to you. That is fine—just give the best answer you can. There are no right or wrong answers.

How will the researchers contact me to do the next survey?

We will collect some information from you that will help us stay in contact with you. We will ask things like your address and phone number so we can send you cards in the mail and call you, and for some names and numbers of people who would know how to contact you if you move. We will keep this information totally private and separate from your survey and school record information. It’s just so we can contact you again.

Do I have to do this?

No, you don’t. You can say that you don’t want to do the survey and that is fine. You can also choose not to answer certain questions even if you do the surveys.

What if the questions are upsetting?

We don’t think you’ll be upset by filling out the survey, but if you are, [Local Resource] is available to talk to and to help. We will also give you a list of places in your community you can call to get help with any of the problems we ask about on the survey.

Are there any benefits to participating?

Although there may not be any direct benefits, you may benefit indirectly from knowing that you have made a contribution to research that will help other parents and teenagers in the future.

OTHER INFORMATION

All the information you give us as part of this study will be kept strictly confidential. Your name will appear on the survey cover sheet, but the name will be removed within [three hours] of the survey administration, and your name will be replaced with a number. The results of this project will be only reported in ways that do not identify individual participants. We will withdraw your responses at any time point, should you make the request.

All questionnaires and records will be kept in locked files and will be retained for a minimum of [three years] after the end of the study. Data will be retained in identifiable form for a period of [three years]. Only researchers at <contractor> will ever have access to any personal data or other identifying information, except as noted below.

Participation in the study is completely voluntary. If you decide to not participate or to withdraw from the study at any time, there will be no penalties or consequences. Please keep a copy of this information sheet for your records. Feel free to contact us at <e-mail> or <phone> if you have any questions or concerns. The investigators are also willing to answer any questions or concerns that might arise after the survey and is willing to provide referral information if your son/daughter would need assistance related to teen dating issues, bullying, or sexual harassment, or if you would like assistance with parenting your teen or with your relationships. You may also contact the <CDC> Institutional Review Board Office at <email> or <phone number>. We look forward to working with you We do not anticipate any foreseeable risks to you and we think that our research will be helpful in designing better intervention programs to improve teen dating relationships.

By signing below, I am indicating that I have read and understand the information above and voluntarily agree to participate in this study.

Signature	Date
Printed Name	Date

School ID number:

Date:

Parent name:

Parent ID number: