Parent/Guardian Consent - High School Chicago

Appendix C3-1:

Parent/Guardian Consent Form for High School Student Participation (Chicago)

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

Dear Parent:

The Centers for Disease Control and Prevention (CDC) is conducting a research project. It is called “Evaluation of CDC’s Dating Matters^®: Strategies to Promote Healthy Teen Relationships Initiative.” The middle school your child attended implemented one of two teen dating violence prevention programs. The purpose of this research study is to see how these programs work. We have been conducting surveys with students before, during and after these programs to see how and if the programs work. You gave consent for us to ask your child complete surveys for this study in middle school. Now that your child has graduated from middle school, on behalf of CDC, NORC at the University of Chicago is asking your child to fill out surveys once a year while they are in high school or high school aged.

Your child does not have to participate. If s/he does participate, his/her information will be kept completely confidential, or private. Please take a few moments to read the enclosed information statement. We hope it will help you to understand what we will be doing and how. We hope you will be as excited about this project as other parents have been.

Sincerely,

Bruce G. Taylor, Ph.D.

Principal Investigator, NORC Evaluation Contract

CDC’s Dating Matters: Strategies to Promote Healthy Teen Relationships^® Initiative

Evaluation of CDC’s Dating Matters: Strategies to Promote Healthy Teen Relationships^® Initiative

Parental Consent for Student Participation: PARENT INFORMATION STATEMENT

RESEARCHERS’ STATEMENT TO PARENTS

We are asking permission for your child to take part in an evaluation study at his/her school. This letter will give you information about the study so you can decide if you want your child to continue to take part in the study. Please read the information carefully. You can call the number at the end of this letter to ask any questions you have about the study. When all of your questions have been answered, you can decide if you want your child to take part in the study.

WHAT IS THE PURPOSE OF THE STUDY?

Your child’s middle school implemented one of two kinds of teen dating violence prevention. Your child’s middle school was one of 12 schools in Chicago that participated in this prevention initiative. The purpose of this research study is to see how these programs work. We have to conduct surveys with teens before, during and after these programs to see how and if the programs work, and whether program effects last after middle school.

WHAT WILL THE SURVEY REQUIRE OF MY CHILD?

We will do surveys with students to help us find out if the programs are working. If you agree to let your child participate, he/she will complete a survey at school. We will do the surveys once a year while your child is in high school or is high school age. The survey will take about 50 minutes to complete. The students will have the choice to mark their answers in a paper survey packet in school. {IF OMB APPROVES WEB SURVEY AND CHICAGO SCHOOLS MIGHT OFFER WEB OPTION IN SCHOOL: Some students may be offered the opportunity to answer the same survey questions at school through a secure online web survey.} Your child may also be able to do the survey over the phone or online if they cannot complete it in school. The survey is entirely voluntary and confidential. Confidential means that you and the school cannot see your child’s answers. Voluntary means that your child can decide not to do the survey. Your child can also skip questions that make him/her feel uncomfortable. No information from the survey or about your child’s participation in this study will be in their school records.

The survey asks your child about their attitudes and behaviors. It asks about their relationships with friends, parents, and dating partners, and their perceptions of relationships between others. Some questions ask about drugs and alcohol and sexual behaviors. Under a law called the Protection of Pupil Rights Act, [20 U.S.C. Section 1232 (c)(1)(A)], you have the right to see a copy of a blank survey and read all the questions. Copies of the survey are available based on your request. If you would like a copy mailed to you, please call 1-800-xxx-xxx>.

HOW WILL YOU PROTECT MY CHILD’S PRIVACY?

All answers that your child gives will be kept private. This is so because this study has been given a Certificate of Confidentiality. This means anything your child tells us will not have to be given out to anyone, even if a court orders us to do so, unless you and your child say it's okay. But under the law, we must report to the proper authorities suspected cases of child abuse or if your child tells us he or she is planning to cause serious harm to themselves or others. This means that if your child tells us verbally that he or she is planning to hurt themselves or someone else, or if your child tells us that someone, either an adult or child is hurting them, then we will have to tell someone so we can get help.

WHAT IS CDC’S DATING MATTERS: STRATEGIES TO PROMOTE HEALTHY TEEN DATING RELATIONSHIPS INITIATIVE?

Preventing teen dating violence means stopping it before it starts. To do this we have to make sure teens’ first dating relationships are healthy ones. CDC’s “Dating Matters^®: Strategies to Promote Healthy Teen Dating Relationships” initiative aims to promote respectful, nonviolent dating relationships among youth. We are doing this by involving youth, parents, schools and the community. Part of this initiative is focused on testing whether these prevention programs work.

ARE THERE ANY RISKS? WILL STUDENTS EXPERIENCE ANY STRESS OR DISCOMFORT?

The survey will be administered at the school by a trained research interviewer from NORC at the University of Chicago. Our interviewers are experienced in working with youth. They will make every effort to provide a comfortable setting while your child completes his/her survey. We will make every effort to respect your child’s privacy. Some questions ask about personal matters. Our interviewers are also trained to be aware of these concerns and will do their best to minimize any discomfort. Also, your child may decline to answer any question he/she does not want to answer. {IF OMB APPROVAL FOR WEB SURVEY RECEIVED: Your child may also be offered the option of completing this survey online at school. Following strict protocols, online survey data will be transferred through a secure server to protect the privacy of your child’s answers. Although we will do our best to protect the privacy of your answers, like all online communications, we cannot guarantee complete confidentiality of data sent over the internet.} If your child does not have an opportunity to complete the survey in school, she/he may also be able to do the survey over the phone {, or} at home, {OMB approval pending: or online}.

WHAT ARE THE BENEFITS OF THE STUDY?

Although there may not be any direct benefits, your child may benefit indirectly by knowing he/she has made a contribution to research that will help others in the future.

OTHER INFORMATION

All the information your child gives as part of this study will be kept strictly confidential. Your child’s survey will only be identifiable from a unique ID number. His/her name will not appear on the completed survey. Information collected will not become part of school records. No one at the school will see your child’s responses. The results of this project will be only reported in ways that do not identify individual participants. We will withdraw your child’s 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 up to three years after the end of the study. Participants’ personal information (name, birthdate, etc.) will be kept for up to three years. Only researchers on the NORC research team and CDC will ever have access to any personal data or other identifying information.

This study is being funded by CDC, which is part of the federal government. Therefore, the data collected as part of this study will be made available to researchers. Other researchers may also examine whether the program worked and how certain things might be related to dating behaviors in teens. No information that could be used to identify your child will be released to these researchers. There would be no way for anyone else to know who was in the study or to know any information that might identify who is in the study.

Participation in the study is completely voluntary. If you or your child decides 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. If you have any questions about this study, you may contact NORC at 1-877-388-6369 or via e-mail at eval@norc.org. We are also willing to answer any questions or concerns that might arise after the survey. We will provide referral information if your son/daughter asks us for assistance related to teen dating issues, bullying, or sexual harassment. You may also contact NORC’s Institutional Review Board Office (NORC IRB Manager, toll-free at 1-866-309-0542). We look forward to working with your child. A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S. Law. This Web site will not include information that can identify you. At most, the Web site will include a summary of the results. You can search this Web site at any time. We do not anticipate any foreseeable risks to your child. We think that our research will be helpful in designing better intervention programs to improve teen dating relationships and to assist in creating a safer school environment for your child.

HOW WILL THE RESEARCHERS CONTACT MY CHILD TO DO THE NEXT SURVEY?

Most participating high school students will fill out the next survey in their classroom. For surveys completed at school, we will collect the survey directly from your child via a postage-paid return envelope addressed to NORC. The completed survey will be returned to NORC using this envelope. The school will not collect, see or keep the survey. For students who are unable to take the annual survey at their high school, we will mail the survey to your home, and then ask your child to return the completed survey to us via a postage-paid return envelope addressed to NORC. The completed survey will be returned to NORC using this envelope. Some students may prefer to answer the survey questions in a telephone interview, with a trained NORC interviewer. {IF OMB APPROVES WEB SURVEY: It also may be an option to answer the survey questions on a secure web survey format.} To contact your child if your child moves, we will need to collect some information from your child that will help us stay in contact with your child if the above approaches do not work. We will ask things like your child’s address and phone number so we can send your child cards in the mail and call your child, and for some names and phone numbers of people who would know how to contact your child if he or she moves (such as a family member). We will keep all contact information totally private and separate from your child’s survey and school record information. It’s just so we can contact your child again.

HOW DO I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN THIS STUDY?

You give permission for your child to participate by checking the appropriate ‘Yes’ box and signing the form. If you do not give your child permission to participate, check the ‘No’ box. By signing below, you agree that you have read the information above. Once signed, return this form to your child’s school.

• Yes, I agree to have my child participate in the surveys.

• No, I do not give consent for my child to participate.

Child Name (please print) Grade Level

Parent Signature Date

Parent Name (please print) Date

Parent Phone Parent Email

Address

City State Zip