OMB Number: 0970-XXXX [Insert logo here]
Expiration Date: XX/XX/XXXX
Dear Parent or Guardian:
The Administration for Children and Families (ACF) is part of the U.S. Department of Health and Human Services. ACF is funding a team at Mathematica Policy Research to learn more about how to teach youth about preventing teen pregnancy and promote sexual health through [interviews/online discussions]. [ORGANIZATION NAME] is taking part in it.
The purpose of the [interviews/online discussion] is to learn more about how youth make decisions related to sexual health, youth experiences with sexual health education, and how these programs could be improved to prevent unintended pregnancy and improve sexual health. We are asking your child to participate in the [online discussion /interview]. During the [online discussion /interview], your child will be asked about his or her experiences with sexual health education programs, how he or she thinks sexual health education programs could work better for youth, how youth make decisions about relationships and sex, and how youth get information about sexual health. His or her point of view is extremely valuable to efforts encouraging the sexual health of youth. The [online discussion/interview] will take no more than ninety minutes to complete.
If you choose to let your child participate, the information from your son/daughter will be combined with information from other youth to describe their experiences with and attitudes toward sexual health education. Your child’s name will not be attached to the answers he or she gives, and no one outside the [online discussion and] study team will see his or her answers. The study team will keep all information collected private to the extent possible by law. [Additionally, the team will ask all participants to keep the information discussed in the online discussion private; however, there is a chance other participating youth may reveal information discussed in the online discussion to people who were not in the online discussion.]
Being part of this [online discussion/interview] is completely voluntary. There are no penalties or consequences to your son/daughter for not answering our questions. We will ask some questions that deal with sensitive topics, like how youth make decisions about relationships and sex. Your child does not have to answer any questions that he or she is not comfortable answering. Your son/daughter may also stop participating in the [online discussion/interview] at any point. There are no right or wrong answers to our questions.
If you agree to let your child participate in the [online discussion/interview], you or your child can choose to stop participation at any time with no consequences. Your child will receive a $20.00 gift card for [participating in the interview/joining the online discussion each day for 3 days]. There are no additional benefits to your child for participating in the [online discussion /interview].
Please let us know whether you will allow your child to participate in the [online discussion/interview] by completing and signing the attached form. Return it to [CONTACT PERSON].
Please call Mathematica toll-free at X-XXX-XXX-XXXX if you have questions about the study.
Sincerely,
Jean Knab, Ph.D.
Project Director
Mathematica Policy Research
Parent or Guardian Consent Form for [Online Discussions/Interviews]
Sponsored by the United States Department of Health and Human Services
I have read the attached information sheet describing the [online discussions/interview]. By signing this form, I am:
□giving my permission □not giving permission
for my son or daughter, ___________________________, to participate in the [online discussions/interview]. Print child’s name
If giving permission for my child to participate in the [online discussions/interview], I understand that my child will be asked about his/her experiences with sexual health education, how these programs could be improved, and decision making about relationships and sex. I agree to this information being collected. Additionally, I understand that participation is voluntary and may be withdrawn at any time for any reason without penalty. I further understand that all information on my child will be kept private by the study team and used only for the purposes of the study. [I also understand the study team will instruct participants to keep the information private, however there is a chance other participants may reveal information discussed in the online discussion to people who were not in the online discussion.] If I have questions about my child’s rights as a research volunteer, I can call the New England Institutional Review Board, toll-free at 1-800-232-9570.
Parent or Guardian Signature: ________________________________ Date: _______________
Child’s Name: ___________________________________________
Child’s Date of Birth: _____ / ______ / _____
Month Day Year
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.
Page
NEIRB Version XX.0
| File Type | application/msword |
| File Title | PAF Consent Letters and Forms and Youth Assent Form |
| Subject | Forms |
| Author | Sara Forrestal |
| Last Modified By | SYSTEM |
| File Modified | 2017-08-03 |
| File Created | 2017-08-03 |