YCC Student BIF Assent Form

Student Assent to Participate in the
Evaluation of Youth CareerConnect (YCC)
As part of your application to [PROGRAM NAME], your parent or guardian has given permission for you
to be part of a research study. The study will help the U.S. Department of Labor (DOL) learn more about
how high schools can help young people succeed after high school. The study is being conducted by
Mathematica Policy Research. As a part of the study, you will be asked to complete a short survey. The
survey will ask about your experiences at school, behavior in school, activities, and plans for future
education. It will also ask some questions about the people who live in your house and how we can
contact you in the future. All the information you give will be protected and used only for research.
Your information may be linked with federal or state administrative data, such as your school grades or
attendance record, for future study purposes.
Your parent/guardian(s) know that you are participating in this study, but you can still decide not to
participate if you don’t want to. Nothing bad will happen to you. You can stop being in the study at any
time.
Being in the study does not mean you will get into the program. Being accepted might be decided by a
lottery that is like flipping a coin to see if you get in.
If you have any questions about the study, please feel free to call Lisbeth Goble at 1-877-523-4651. If
you have any questions about your rights as a research volunteer, please call the New England
Institutional Review Board at 1-800-232-9570.
Please read the statements below and check one of the boxes.

The study was explained to me and I want to participate.

The study was explained to me and I do not want to participate.
Then please sign your name on the line below.
_____________________________________________________________
Signature

________________________
Date

_____________________________________________________________
Print Name

If requested, you will be sent a copy of this form to keep for yourself.

We will do everything we can to keep others from learning about your participation in this study. To further help us protect your privacy, we have obtained a
Certificate of Confidentiality from the U.S. Department of Health and Human Services (DHHS). With this Certificate, we cannot be forced (for example by court
order or subpoena) to disclose information that may identify you in any federal, state, local, civil, criminal, legislative, administrative, or other proceedings. The
researchers will use the Certificate to resist any demands for information that would identify you or your child, except to prevent serious harm to you or others, and
as explained below.
You should understand that a Certificate of Confidentiality does not prevent you, or a member of your family, from voluntarily releasing information about yourself or
your child, or your involvement in this study. If an insurer or employer learns about your participation, and obtains your consent to receive research information,
then we may not use the Certificate of Confidentiality to withhold this information. This means that you and your family must also actively protect your own privacy.
You should understand that we will in all cases, take the necessary action, including reporting to authorities, to prevent serious harm to yourself, children, or others.
For example, in the case of child abuse or neglect. A Certificate of Confidentiality does not represent an endorsement of the research study by DHHS or the
National Institutes of Health.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays an Office of Management and Budget (OMB) control
number. The valid OMB control number for this information collection is 1291-0003. The time required to complete this collection of information is estimated to average 1 minute, including the time to review
instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to Molly Irwin at 202-693-5091 or [email protected] and reference the OMB Control Number1291-0003.

Federal Law called the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of your education records. Generally,
schools must have permission from you or your parent in order to release your education records.

Approved by NEIRB on 6/4/2015
NEIRB Version 2.0