Appendix D. Consent Forms

Appendix D. Consent Forms

Informed Assent for Participants Under 18
Practitioner-Administered
OVERVIEW
The Urban Institute is conducting a study sponsored by the U.S. Department of Health and Human
Services to examine the intersection of domestic human trafficking with child welfare and
runaway and homeless youth programs. The goal of this study is to pre-test and further develop a
screening tool intended to identify victims of human trafficking among child welfare-involved and
runaway and homeless youth-involved youth populations. Improved screening for cases of human
trafficking among this population will help service providers better target and deliver services to
those who need them.
PROCEDURES
If you are between the ages of 12 and 24 and involved in the child welfare system or receiving
runaway and homeless youth services, you are invited to participate in this study. I am reading you
the assent procedures for a participant under the age of 18 based on your age that you told me—
please correct me if you are not under the age of 18. Giving us your “informed assent” means that
you understand the risks and benefits of this study and actively agree to participate in it. If you
choose to participate, I will ask you a series of questions and record your responses on a
computer/tablet or piece of paper. This should take approximately 15 minutes. You will receive
a $25 gift card as a token of thanks for participating in the study.
During the study, you will be asked questions about experiences trading sex for money, food,
shelter, drugs, etc., in addition to experiences involving being forced or manipulated into working
for someone who used abusive labor practices. You may refuse to answer any questions or stop
your participation in this study at any time and for any reason.
PRIVACY
Everything you tell me will be private to the extent permitted by law. I will not ask you your name
or have you write or sign your name anywhere, and the people who see your answers will not
know your name. In order to keep your participation in this study private, we ask that you not
discuss what you (or others) say during the course of the study. No one except me will know that
you are the person who responded to these questions today. There are three exceptions to this
promise of privacy:
1. If you tell me you are going to hurt yourself badly, or I think you might try to kill yourself, I
will get help for you by reporting the situation to the appropriate authorities. I will not ask
you any questions about this, but if you choose to talk to me about it, I will have to alert
authorities.

The described collection of information is voluntary. 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 number for this information collection is [NUMBER] and the expiration date is [DATE].

2100 M Street NW
Washington DC
20037
urban.org

2. If you tell me you are going to hurt someone else or you are aware of serious harm that may
be done to someone else, I will take steps to protect that person by reporting the situation
to the appropriate authorities. I will not ask you any questions about this, but if you choose
to talk to me about it, I will have to alert authorities.
3. Any case of suspected physical or sexual abuse and/or neglect of children (anyone under
the age of 18, including yourself and others) must be reported to Child Protective Services.
I will ask you some questions that relate to physical or sexual abuse or neglect that you
have faced. For example, to determine whether you are a victim of human trafficking, I will
ask you if someone has forced you to do work without paying you or to engage in sexual
acts. If you answer “yes” to any of these types of questions, you are admitting to being a
victim of a form of child abuse. I am required to report any child abuse to Child Protective
Services. In summary, IF YOU DISCLOSE ANY CHILD ABUSE TO ME, YOUR RESPONSE
WILL NO LONGER BE ANONYMOUS. I will have to report such abuse and include your
name in the report.
RISKS AND BENEFITS
Some questions may make you sad or bring up bad memories. You may refuse to answer any
questions or end your participation at any time, and doing so will NOT affect any services you may
be receiving. You will also be given a resource referral card prior to beginning the study. This card
will list local resources and social workers who are available to help you if you feel distressed after
the study is completed. We also have emergency phone numbers on hand at all times, and we
would be happy to connect you with immediate services either during or after the study, if you
request that we do so.
One benefit of participating in this study is that you will be providing important information that
will help agencies develop more targeted and effective services for young people at-risk for
human trafficking. Many young people also appreciate the opportunity to share or reflect on their
life experiences through participation in this research. Further, participating in this research will
give you the opportunity to connect with resources and express your specific needs, if you choose
to do so.
CONTACT INFORMATION
Should you have any further questions, you may contact Meredith Dank ([email protected]; 347404-7990) or Mike Pergamit ([email protected]; 202-261-5276). You can also contact the
Urban Institute’s Institutional Review Board by contacting Haley Vandermeer
([email protected]; 202-261-5661).

2100 M Street NW
Washington DC
20037
urban.org

PARTICIPANT’S INFORMED ASSENT
Giving us your “informed assent” means that you understand the risks and benefits of this study
and actively agree to participate in it. We are now going to ask you to say out loud whether you
agree to participate in this study. If you agree to participate, you are agreeing that:
•
•
•

•
•
•

•

I understand that I will receive a $25 gift card as a token of thanks for my participation
in the study.
I understand that all the information that I provide will remain private to the extent
permitted by law.
I understand that if I disclose any child abuse or talk about my intent to harm myself or
harm someone else, the situation will be reported and my participation and my
responses with respect to self-harm, harm of others, or child abuse will no longer be
private.
I understand that my participation is voluntary and that I may stop at any time or skip
any questions.
I understand that if I stop participating or skip questions, the services I may be
receiving will not be affected.
I know that if I have any questions about this study, I can talk with someone at the
agency where I was interviewed and they will answer my questions; or I can contact
someone from the Urban Institute at one of the numbers listed under “Contact
Information.”
I agree to the study’s purpose and my involvement.

If you are not sure whether you understand everything I just read, I will be happy to answer any
questions you have now, or I can give you some time to talk to agency staff before you decide. Do
you agree to participate in this study?

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to
examine the intersection of domestic human trafficking with child welfare and runaway and homeless youth
programs. Public reporting burden for this collection of information is estimated to average 17 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed, and
reviewing the collection of information. 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
number for this information collection is [NUMBER] and the expiration date is [DATE]. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to Meredith Dank; [email protected].

2100 M Street NW
Washington DC
20037
urban.org

Informed Assent for Participants Under 18
Self-Administered
OVERVIEW
The Urban Institute is conducting a study sponsored by the U.S. Department of Health and Human
Services to examine the intersection of domestic human trafficking with child welfare and
runaway and homeless youth programs. The goal of this study is to pre-test and further develop a
screening tool intended to identify victims of human trafficking among child welfare-involved and
runaway and homeless youth-involved youth populations. Improved screening for cases of human
trafficking among this population will help service providers better target and deliver services to
those who need them.
PROCEDURES
If you are between the ages of 12 and 24 and involved in the child welfare system or receiving
runaway and homeless youth services, you are invited to participate in this study. If you are
reading this form, you should be UNDER the age of 18—if you are 18 or older, please request a
different paper form or click back in your browser and select your appropriate age group. If you
choose to participate, you will fill out a brief multiple choice survey using either paper and pencil or
a computer/tablet. This should take approximately 15 minutes. You will receive a $25 gift card as
a token of thanks for participating in the study.
On the survey, you will be asked questions about experiences trading sex for money, food, shelter,
drugs, etc., in addition to experiences involving being forced or manipulated into working for
someone who used abusive labor practices. You may skip over any questions or stop your
participation in the survey at any time and for any reason.
PRIVACY
Everything you report on the survey will be private to the extent permitted by law. You will not
write or sign your name anywhere, and the people who see your answers will not know your name
or that you are the person who selected your answers. In order to keep your participation in this
study private, we ask that you not discuss what you (or others) report during the course of the
study.
We ask that you only respond to the multiple choice questions on the survey and do not write
anything in the margins, if you are completing the survey by hand. If, for any reason, you do write
anything on the paper survey, please be aware that we will not be able to link the writing to your
identity.

The described collection of information is voluntary. 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 number for this information collection is [NUMBER] and the expiration date is [DATE].

2100 M Street NW
Washington DC
20037
urban.org

We also ask that you do not speak out loud while taking the survey, except to ask questions. We
will not ask you to speak out loud at any point. However, if you do speak out loud, you should be
aware that doing so invokes three exceptions to our promise of complete privacy:
1. If while you are filling out the survey, you say that you are going to hurt yourself badly or
try to kill yourself, I will get help for you by reporting the situation to the appropriate
authorities.
2. If while you are filling out the survey, you say that you are going to hurt someone else or
you are aware of serious harm that may be done to someone else, I will take steps to
protect that person by reporting the situation to the appropriate authorities.
3. If while you are filling out the survey, you verbally report a case of suspected physical or
sexual abuse and/or neglect of children (anyone under the age of 18, including yourself and
others), I must report it to Child Protective Services. In other words: IF YOU VERBALLY
DISCLOSE ANY CHILD ABUSE TO ME, YOUR RESPONSE WILL NO LONGER BE
ANONYMOUS. I will have to report such abuse and include your name in the report.
RISKS AND BENEFITS
Some questions may make you sad or bring up bad memories. You may refuse to answer any
questions or end your participation at any time, and doing so will NOT affect any services you may
be receiving. You will also be given a resource referral card prior to beginning the study. This card
will list local resources and social workers who are available to help you if you feel distressed after
the study is completed. We also have emergency phone numbers on hand at all times, and we
would be happy to connect you with immediate services either during or after the study, if you
request that we do so.
One benefit of participating in this study is that you will be providing important information that
will help agencies develop more targeted and effective services for young people at-risk for human
trafficking. Many young people also appreciate the opportunity to share or reflect on their life
experiences through participation in this research. Further, participating in this research will give
you the opportunity to connect with resources and express your specific needs, if you choose to do
so.
CONTACT INFORMATION
Should you have any further questions, you may contact Meredith Dank ([email protected]; 347404-7990) or Mike Pergamit ([email protected]; 202-261-5276). You can also contact the
Urban Institute’s Institutional Review Board by contacting Haley Vandermeer
([email protected]; 202-261-5661).

2100 M Street NW
Washington DC
20037
urban.org

PARTICIPANT’S INFORMED ASSENT
Giving us your “informed assent” means that you understand the risks and benefits of this study
and actively agree to participate in it. By filling out the survey, you are agreeing to participate and
agreeing that:
•
•
•

•
•
•

•

I understand that I will receive a $25 gift card as a token of thanks for my
participation in the study.
I understand that all the information that I provide will remain private to the
extent permitted by law.
I understand that if I disclose any child abuse or talk about my intent to harm myself
or harm someone else, the situation will be reported and my participation and my
responses with respect to self-harm, harm of others, or child abuse will no longer be
private.
I understand that my participation is voluntary and that I may stop at any time or
skip any questions.
I understand that if I stop participating or skip questions, the services I may be
receiving will not be affected.
I know that if I have any questions about this study, I can talk with someone at the
agency where I was interviewed and they will answer my questions; or I can contact
someone from the Urban Institute at one of the numbers listed under “Contact
Information.”
I agree to the study’s purpose and my involvement.

If you are not sure whether you understand everything you just read, agency staff will be happy to
answer any questions you have now, or you can take some time to talk to agency staff before you
decide whether or not to continue.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to examine the
intersection of domestic human trafficking with child welfare and runaway and homeless youth programs. Public reporting
burden for this collection of information is estimated to average 17 minutes per response, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 number for this information collection is [NUMBER] and the expiration date is [DATE]. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to Meredith Dank; [email protected].

2100 M Street NW
Washington DC
20037
urban.org

Informed Consent for Participants Age 18 and Older
Practitioner-Administered
OVERVIEW
The Urban Institute is conducting a study sponsored by the U.S. Department of Health and Human
Services to examine the intersection of domestic human trafficking with child welfare and
runaway and homeless youth programs. The goal of this study is to pre-test and further develop a
screening tool intended to identify victims of human trafficking among child welfare-involved and
runaway and homeless youth-involved youth populations. Improved screening for cases of human
trafficking among this population will help service providers better target and deliver services to
those who need them.
PROCEDURES
If you are between the ages of 12 and 24 and involved in the child welfare system or receiving
runaway and homeless youth services, you are invited to participate in this study. I am reading you
the consent procedures for a participant age 18 or older based on your age that you told me—
please correct me if you are not at least 18 years old. Giving me your “informed consent” means
that you understand the risks and benefits of this study and actively agree to participate in it. If
you choose to participate, I will ask you a series of questions and record your responses on a
computer/tablet or piece of paper. This should take approximately 15 minutes. You will receive
a $25 gift card as a token of thanks for participating in the study.
During the study, you will be asked questions about experiences trading sex for money, food,
shelter, drugs, etc., in addition to experiences involving being forced or manipulated into working
for someone who used abusive labor practices. You may refuse to answer any questions or stop
your participation in this study at any time and for any reason.
PRIVACY
Everything you tell me will be private to the extent permitted by law. I will not ask you your name
or have you write or sign your name anywhere, and the people who see your answers will not
know your name. In order to keep your participation in this study private, we ask that you not
discuss what you (or others) say during the course of the study. No one except me will know that
you are the person who responded to these questions today. There are three exceptions to this
promise of privacy:
1. If you tell me you are going to hurt yourself badly, or I think you might try to kill yourself, I
will get help for you by reporting the situation to the appropriate authorities.
2. If you tell me you are going to hurt someone else or you are aware of serious harm
that may be done to someone else, I will take steps to protect that person by
reporting the situation to the appropriate authorities.

The described collection of information is voluntary. 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 number for this information collection is [NUMBER] and the expiration date is [DATE].

2100 M Street NW
Washington DC
20037
urban.org

3. Any case of suspected physical or sexual abuse and/or neglect of children (not
yourself, since you are 18 or older, but anyone else who is under 18) must be reported
to Child Protective Services.
I will NOT ask you any questions about these three things, but if you choose to talk to me about
any of them, I will have to alert authorities.
RISKS AND BENEFITS
Some questions may make you sad or bring up bad memories. You may refuse to answer any
questions or end your participation at any time, and doing so will NOT affect any services you may
be receiving. You will also be given a resource referral card prior to beginning the study. This card
will list local resources and social workers who are available to help you if you feel distressed after
the study is completed. We also have emergency phone numbers on hand at all times, and we
would be happy to connect you with immediate services either during or after the study, if you
request that we do so.
One benefit of participating in this study is that you will be providing important information that
will help agencies develop more targeted and effective services for young people at-risk for
human trafficking. Many young people also appreciate the opportunity to share or reflect on their
life experiences through participation in this research. Further, participating in this research will
give you the opportunity to connect with resources and express your specific needs, if you choose
to do so.
CONTACT INFORMATION
Should you have any further questions, you may contact Meredith Dank ([email protected]; 347404-7990) or Mike Pergamit ([email protected]; 202-261-5276). You can also contact the
Urban Institute’s Institutional Review Board by contacting Haley Vandermeer
([email protected]; 202-261-5661).

2100 M Street NW
Washington DC
20037
urban.org

PARTICIPANT’S INFORMED CONSENT
Giving us your “informed consent” means that you understand the risks and benefits of this study
and actively agree to participate in it. We are now going to ask you to say out loud whether you
agree to participate in this study. If you agree to participate, you are agreeing that:
•
•
•
•
•
•
•

I understand that I will receive a $25 gift card as a token of thanks for my participation in
the study.
I understand that all the information that I provide will remain private to the extent
permitted by law.
I understand that if I disclose any child abuse or talk about my intent to harm myself or
harm someone else, the situation will be reported and my participation and my responses
with respect to self-harm, harm of others, or child abuse will no longer be private.
I understand that my participation is voluntary and that I may stop at any time or skip any
questions.
I understand that if I stop participating or skip questions, the services I may be receiving
will not be affected.
I know that if I have any questions about this study, I can talk with someone at the agency
where I was interviewed and they will answer my questions; or I can contact someone from
the Urban Institute at one of the numbers listed under “Contact Information.”
I agree to the study’s purpose and my involvement.

If you are not sure whether you understand everything I just read, I will be happy to answer any
questions you have now, or I can give you some time to talk to agency staff before you decide. Do
you agree to participate in this study?

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to
examine the intersection of domestic human trafficking with child welfare and runaway and homeless youth
programs. Public reporting burden for this collection of information is estimated to average 17 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed, and
reviewing the collection of information. 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
number for this information collection is [NUMBER] and the expiration date is [DATE]. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to Meredith Dank; [email protected].

2100 M Street NW
Washington DC
20037
urban.org

Informed Consent for Participants 18 and Older
Self-Administered
OVERVIEW
The Urban Institute is conducting a study sponsored by the U.S. Department of Health and Human
Services to examine the intersection of domestic human trafficking with child welfare and
runaway and homeless youth programs. The goal of this study is to pre-test and further develop a
screening tool intended to identify victims of human trafficking among child welfare-involved and
runaway and homeless youth-involved youth populations. Improved screening for cases of human
trafficking among this population will help service providers better target and deliver services to
those who need them.
PROCEDURES
If you are between the ages of 12 and 24 and involved in the child welfare system or receiving
runaway and homeless youth services, you are invited to participate in this study. If you are
reading this form, you should be 18 OR OLDER—if you are under 18, please request a different
paper form or click back in your browser and select your appropriate age group. If you choose to
participate, you will fill out a brief multiple choice survey using either paper and pencil or a
computer/tablet. This should take approximately 15 minutes. You will receive a $25 gift card as a
token of thanks for participating in the study.
On the survey, you will be asked questions about experiences trading sex for money, food, shelter,
drugs, etc., in addition to experiences involving being forced or manipulated into working for
someone who used abusive labor practices. You may skip over any questions or stop your
participation in this study at any time and for any reason.
PRIVACY
Everything you report on the survey will be private to the extent permitted by law. You will not
write or sign your name anywhere, and the people who see your answers will not know your name
or that you are the person who selected your answers. In order to keep your participation in this
study private, we ask that you not discuss what you (or others) report during the course of the
study.
We ask that you only respond to the multiple choice questions on the survey and do not write
anything in the margins, if you are completing the survey by hand. If, for any reason, you do write
anything on the paper survey, please be aware that we will not be able to link the writing to your
identity.

The described collection of information is voluntary. 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 number for this information collection is [NUMBER] and the expiration date is [DATE].

2100 M Street NW
Washington DC
20037
urban.org

We also ask that you do not speak out loud while taking the survey, except to ask questions. We
will not ask you to speak out loud at any point. However, if you do speak out loud, you should be
aware that doing so invokes three exceptions to our promise of complete privacy:
1. If while you are filling out the survey, you say that you are going to hurt yourself badly or
try to kill yourself, I will get help for you by reporting the situation to the appropriate
authorities.
2. If while you are filling out the survey, you say that you are going to hurt someone else or
you are aware of serious harm that may be done to someone else, I will take steps to
protect that person by reporting the situation to the appropriate authorities.
3. If while you are filling out the survey, you verbally report a case of suspected physical or
sexual abuse and/or neglect of children (not yourself, since you are 18 or older, but anyone
else who is under 18), I must report it to Child Protective Services.
RISKS AND BENEFITS
Some questions may make you sad or bring up bad memories. You may refuse to answer any
questions or end your participation at any time, and doing so will NOT affect any services you may
be receiving. You will also be given a resource referral card prior to beginning the study. This card
will list local resources and social workers who are available to help you if you feel distressed after
the study is completed. We also have emergency phone numbers on hand at all times, and we
would be happy to connect you with immediate services either during or after the study, if you
request that we do so.
One benefit of participating in this study is that you will be providing important information that
will help agencies develop more targeted and effective services for young people at-risk for
human trafficking. Many young people also appreciate the opportunity to share or reflect on their
life experiences through participation in this research. Further, participating in this research will
give you the opportunity to connect with resources and express your specific needs, if you choose
to do so.
CONTACT INFORMATION
Should you have any further questions, you may contact Meredith Dank ([email protected]; 347404-7990) or Mike Pergamit ([email protected]; 202-261-5276). You can also contact the
Urban Institute’s Institutional Review Board by contacting Haley Vandermeer
([email protected]; 202-261-5661).

2100 M Street NW
Washington DC
20037
urban.org

PARTICIPANT’S INFORMED CONSENT
Giving your “informed consent” means that you understand the risks and benefits of this study and
actively agree to participate in it. By filling out the survey, you are agreeing to participate and
agreeing that:
•
•
•
•
•
•
•

I understand that I will receive a $25 gift card as a token of thanks for my participation in
the study.
I understand that all the information that I provide will remain private to the extent
permitted by law.
I understand that if I disclose any child abuse or talk about my intent to harm myself or
harm someone else, the situation will be reported and my participation and my responses
with respect to self-harm, harm of others, or child abuse will no longer be private.
I understand that my participation is voluntary and that I may stop at any time or skip any
questions.
I understand that if I stop participating or skip questions, the services I may be receiving
will not be affected.
I know that if I have any questions about this study, I can talk with someone at the agency
where I was interviewed and they will answer my questions; or I can contact someone from
the Urban Institute at one of the numbers listed under “Contact Information.”
I agree to the study’s purpose and my involvement.

If you are not sure whether you understand everything you just read, agency staff will be happy to
answer any questions you have now, or you can take some time to talk to agency staff before you
decide whether or not to continue.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to
examine the intersection of domestic human trafficking with child welfare and runaway and homeless youth
programs. Public reporting burden for this collection of information is estimated to average 17 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed, and
reviewing the collection of information. 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
number for this information collection is [NUMBER] and the expiration date is [DATE]. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to Meredith Dank; [email protected].

2100 M Street NW
Washington DC
20037
urban.org