Child Assent form

Appendix A.3.- The Family Options Study

Child Assent Form— Children 8-17 years old

Purpose (What is this about?)

I work for a survey company called Abt SRBI. Abt SRBI is located in Cambridge, MA. We are trying to learn which kinds of housing and services help children and families the most. We are interested in learning more about how you and other people your age think and feel about different things. You may remember completing a short interview with me or one of my coworkers about a year and a half ago.

What are we asking you to do?

We would like to ask you some questions again. We will ask you to answer some questions about personal feelings and school. The questions will take no more than 30 minutes to answer. Your parent(s) have said it is okay that you answer these questions. Even though your parents said yes you can participate, you can decide whether you want to answer these questions or not.

There is no right or wrong answer to my questions. I am interested in your ideas and opinions. The information the researchers learn may help you or other children and families in the future.

Can you say “No”?

Yes. You do not have to answer any questions you do not want to.. Some of the questions may make you sad or embarrass you a little. If you do not feel like answering a question, that’s okay. We can just skip that question and go onto the next one. If you don’t want to answer any more questions, please tell me. We can stop these at any time. No one will be upset with you if you say “no” or if you say “yes” and then change your mind. Remember, if you have any questions about the study, just ask me.

Protecting your information.

Your answers will be kept private. Any information that the researchers collect about you will be kept private and protected to the extent allowed by the Privacy Act.¹

Your Mom/Dad won’t be able to hear what we’re talking about and I won’t tell them any of your answers. Please be honest when you answer the questions. Your name will not be kept with your answers, so no one will know how you answered these questions. Files with your answers will have a special identification number on them.

We will do everything we can to make sure other people don’t know that you participated in this study. We have a certificate from the U.S. government that adds special protection for the information that identifies you. It doesn’t mean that the government thinks that our project is a good idea or not. It does say that we do not have to identify you, even if a judge asks us to. However, if keeping the information you tell us private could mean that you or someone else could be hurt, we may tell someone to keep you safe.

At the end of the study, Abt staff will give all data collected to the agency that paid for this study, the Department of Housing and Urban Development or HUD. HUD will also keep your information private.

Statement of Assent

“I have read this form, or had it read to me. I know that any information I provide will be kept private, unless keeping it privatel could lead to harm to me or others. I understand that my parent gave permission for me to participate in this survey. I know that I can choose not to participate in the survey but if I do participate in the survey, I can refuse to answer any questions or stop the interview at any time without penalty. I understand that my parents will not see my answers. By checking the box below and signing this form, I am agreeing to participate in the study.”

Yes, I want to participate in this study____ No, I do not want to participate in this study____

/ /

Name of Participant (printed) Signature of Participant Date

Printed Name of Child Signature of Child Date

____________________________________ ____________________________________ __________________

Printed Name of Interviewer Signature of Interviewer Date

COMPLETE IF INTERVIEW COMPLETED BY PHONE:

Verbal Consent Obtained: YES NO DATE:________________________

_____________________________________ __________________________________

Name of Interviewer Signature of Interviewer

1 Privacy Act Statement: HUD’s authoritative and principle purpose, conditions of uses, and impacts, if any, for not participating in the survey are referenced within the participant agreement. HUD’s statutory authority for collecting this data can be found at Section 502 (g) of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. 1701z-1; 1701z-2(d) and (g)).