YCC Parent BIF Consent Form

EVALUATION OF YOUTH CAREERCONNECT (YCC)
PARENT CONSENT FORM
1.

Please read the following statement.
The program your student is applying to is part of a national study sponsored by the U.S. Department of Labor (DOL). This
important study will help DOL learn more about how high schools can help young people succeed after high school. There are no
clear risks to participating in the study. There are also no direct benefits to you or your student; however, society at large might
benefit from the study by better understanding what features of high school help students most. This study is conducted by
Mathematica Policy Research.
I understand that by giving permission for my student to be in the study:
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Mathematica can use my student’s information below and can obtain my student’s school records. This includes
information like attendance, test scores, or grades.
I will be asked a few questions about my household.
My student will be asked to complete a short survey related to his or her experiences at school, behavior in school, activities,
and plans for future education.
My student will be contacted in about three years to complete another survey.
My student might be asked to participate in brief interviews or focus groups to discuss his or her experiences. I give
permission for these interviews or focus group discussions to be audio taped.
My student’s information may be linked with federal or state administrative data for future study purposes.

I understand that all information provided to the study will be protected from unauthorized disclosure as required by the Family
Educational Rights and Privacy Act (FERPA).
Agreeing to be in this study does not guarantee that my student will get into the [PROGRAM NAME]. Acceptance might be
determined by a lottery of applicants to the program. I understand that this lottery will be a random process, like flipping a coin. It
has nothing to do with my student’s age, race, gender, or anything else about me or my student. I understand that if my student
does not get accepted into the program, he or she will not be able to be in it for three years. If my student does not enroll in
[PROGRAM NAME], he or she will still be part of the study.
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. Its toll-free number is 1-800232-9570.
2.

After reading this statement, do you give permission for your student to participate in the study?

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YES, ___________________________________________________, CAN participate in the study and I authorize
First Name

Last Name

his or her school, district, or state to release his or her student administrative records.
Student’s Date of Birth: |

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Month
Day

Student’s Social Security Number: |

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Year

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Student’s Gender:  Male

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 Female

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NO, I do not consent for ________________________________________________, to participate in the study.
First Name

Parent/Guardian Signature

Last Name

Date

Print Parent/Guardian Name
*Please return this form to the program along with your completed student application form.
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 Number 1291-0003.
We will do everything we can to keep unaffiliated third parties 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 voluntaril y 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, t hen 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, we will comply with all child abuse and neglect mandatory reporting laws. A Certificate of Confidentiality does not represent an endorsement of
the research study by DHHS or the National Institutes of Health .
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. When you sign this form, you will give permission to the study team to get your education records.

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