Hospital-based Father/Partner Assent - English

PATERNAL/PARTNER ASSENT PRAMS-ZPER Page 3 of 3

PR DEPARTMENT OF HEALTH

MATERNAL, CHILD AND ADOLESCENT HEALTH DIVISION

ASSENT FORM FOR PARTICIPATION IN

ZIKA POSPARTUM EMERGENCY RESPONSE SURVEY (PR-ZPER)

Assent Form for Children 7 to 14 years old

TITTLE OF THE STUDY: Puerto Rico Pregnancy Risk Assessment Monitoring System Zika Pospartum Emergency Response (PRAMS-ZPER)

PROTOCOL NUMBER: B1020117

INVESTIGATORS: Manuel I. Vargas Bernal, Principal Investigator and personnel of PR Department of Health.

PLACE: The study will take place in 33 birthing hospitals in Puerto Rico with 100 or more births in 2016.

TELEPHONE NUMBERS: Maternal, Child and Adolescent Health Division: (787) 765-2929 extension 4672, 4805, 4804 and 4806.

This assent form can be difficult to understand and may have information that you do not understand. Please, feel free to ask to the interviewer to clarify any questions that you may have about this study. Also you may ask the interviewer to talk with you privately or ask her to read you this assent form.

What is the study about?

We are conducting a study called “Zika Postpartum Emergency Response Survey” (ZPER). The purpose of this study is to learn more about the Zika virus and related attitudes and behaviors among people who recently had a baby or a pregnant partner.

What is going to happen with me on this study?

Young people like you may participate on this study. You will be asked to complete a survey with some questions about your experiences. Your participation is completely voluntary; no one can force you to participate.

Why was I selected to participate?

You were selected because you recently had a baby or a pregnant partner in one of the 33 hospitals that were chosen to participate in this survey.

What do I have to do?

You would have to answer a survey (in paper or electronic form) that has questions about pregnancy, some questions about you, and other questions related to Zika virus infection. You will decide what form of the questionnaire you want to use to answer the survey, paper or electronic. It will take only 20 minutes for you to answer. Your questionnaire can be linked with other sources of information available to the Puerto Rico Department of Health.

After you complete the survey, the interviewer will give you the opportunity to receive a short educational intervention that will take aproximately 15 minutes. You may choose to participate or not. The educational intervention will give you information about things you can do or things to expect after the birth of a baby.

How many people will be in this study?

Around 2,000 young people like you would be selected to participate in the study.

Can something bad happen to me?

Nothing bad will happen to you. You only have to answer some questions that will be given to you. But if you feel uncomfortable answering some questions, you do not need to answer them, you can choose.

Why should I participate in this study?

The information you provide will help improve the services families receive, especially regarding Zika virus during pregnancy. We may apply for funding opportunities to improve education, and support during pregnancy for families in Puerto Rico.

Do I have other options?

You can decide which questions you want to answer. You can also leave any questions you do not want to answer blank, you can leave the questionnaire blank or decide not to participate in the study.

What happens if I don’t want to participate in the study?

If you do not want to participate just let the interviewer know about your decision.

If you want to participate in this study, we need you to sign this assent form in the line below. Signing this assent means that you want to participate in this study. Even though you have signed this assent, you can leave the study at any moment if you do not wish to continue.

SIGNATURES FOR THE STUDY

Participant’s Name & Middle Name (Print letter)

Participant’s (Paternal) Last Name (Print letter)

Participant’s (Maternal) Last Name (Print letter)

x_________________________________________________________ _____/_____ /________

Participant’s Signature Date (month/day/year)

“I was present when__________________________ read this consent and say that she or he wanted

^{Participant’s Name}

to participate in this study”

__________________________________________________________

Interviewer/Surveyor Printed Name

x_________________________________________________________ _____ /_____ /________

Interviewer/Surveyor Signature Date (month/day/year)

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