Att_B.3_Parent permission_form

Attachment B.3

Parent Permission Form

RIViR Study

RIViR Study

Parent Permission Form (for Youth Younger than Age 18)

We are inviting your child to be part of a research study with [PROGRAM NAME] as part of our involvement with the Administration for Children and Families’ Healthy Marriage and Relationship Education Program. Your child was chosen because of his/her involvement with [PROGRAM NAME]. This information will be used to help improve programs like ours. Before you decide whether you want your child to take part in this study, we ask that you read this consent form so that you understand what the study is about and what your child will be asked to do.

PURPOSE

In this study we are testing ways to ask youth who are served by programs like [PROGRAM NAME] about their romantic relationships. This study is sponsored by the Office of Planning, Research and Evaluation within the Administration on Children and Families. It is being conducted by RTI International, a non-profit research firm in North Carolina. The study will involve up to 1200 youth and adult participants at multiple locations around the country.

PARTICIPATION IN THE STUDY

If you agree to let your child participate, he or she will be asked a series of questions about romantic relationships, including experiences with unhealthy relationship behaviors and violence. The questions will ask about his or her personal experiences with romantic or intimate partners, such as boyfriends or girlfriends. He or she will also receive written information about teen dating violence and healthy relationships and will be asked some questions after receiving it. There will be two surveys and one interview at three different times over the course of about 2 months. Your child will complete the two surveys on a tablet. A [PROGRAM NAME] staff member will ask your child the interview questions in person. There are no right or wrong answers. Youth do not have to be in a relationship to be in the study. The answers you give will be used for RTI’s study and may also be used by [PROGRAM NAME] staff to determine whether to offer your child any additional services. In addition, RTI will receive information on your child’s age, race and ethnicity, and other personal characteristics collected by [PROGRAM NAME].

VOLUNTARY PARTICIPATION

Your child’s decision to take part in this research study is completely voluntary. You do not have to agree to allow your child to participate in order for him or her to get services from [PROGRAM NAME] or anywhere else. Your child will also be asked if he or she is willing to voluntarily participate in the study. In order for your child to participate, BOTH you and your child must agree to this. If your child does participate in the study, he or she can skip any questions or leave the study at any time.

STUDY DURATION

The two surveys will take about 10 minutes each to complete, and the interview will take about 15 minutes. Your child will be asked the first set of questions in the next few weeks. He or she will be asked another set of questions in approximately 1 month, and a third set of questions about 1 month after that.

POSSIBLE RISKS OR DISCOMFORTS

Some of the questions may seem personal or may bother your child. If he or she feels uncomfortable or upset during the surveys or interview, he or she may skip any of the questions or stop answering questions. The other risk is that someone might find out your child’s answers during the interview or surveys. In order to avoid that, we will do the interview in a private setting where no one can overhear the answers. We will try to make sure that no one can see your child’s answers during the surveys. Also, we will handle and store all of the information your child provides to us in a secure manner.

BENEFITS

There are no direct benefits to your child from participating in this study. However, the study results could help service providers learn about ways to improve services. By participating, your child is also helping us learn more about the kinds of services that might help other youth who participate in healthy relationship education.

TOKEN OF APPRECIATION

Your child will receive a $5 gift card after answering each set of questions as a token of appreciation.

PRIVACY

We will do our best to keep all of the answers to the questions private. Only the people working on the study or with [PROGRAM NAME] will be able to see their answers. No one else, including you or your child’s boyfriend or girlfriend, will be able to find out their answers. Your child’s name will be replaced with a number for the purposes of this study. The project staff will not share your child’s information with anyone outside the study, except under certain circumstances if your child gives permission (for example, for us to refer him or her to [DOMESTIC VIOLENCE PARTNER]). There are two other exceptions: 1) If your child tells us that someone’s life or health could be in danger, and 2) if he or she tells us that a child is being abused or neglected. If this happens, we may need to report to someone whose job it is to see that your child and/or others are safe and protected. We may want to share the results of the study with other people who worked on the study and the funding agency, but no names or other personal information will be included. After all interviews and surveys are completed, a summary will be written that contains information from all participants. The staff doing the study will not use your child’s name in any reports.

The Institutional Review Boards (IRB) at RTI and at [LOCAL IRB INSTITUTION] have reviewed this research. An IRB is a group of people who are responsible for making sure that the rights of participants in research are protected.

FUTURE CONTACTS

If your child participates in this study, we will contact him or her to answer questions two more times, over the course of the next 2 months.

QUESTIONS

If you have any questions about this study, you can contact the [PROGRAM NAME] Project Director, [PROGRAM DIRECTOR], at [LOCAL NUMBER] or Tasseli McKay at RTI at (800) 334-8571 ext. 25747 (a toll-free number). If you have any questions about protecting your child’s privacy or about your child’s rights as a participant, please call [LOCAL IRB LIAISON NAME] at [LOCAL NUMBER].

RTI ID:

COMPLETE AND RETURN THIS FORM TO [NAME OF PROGRAM DATA COLLECTOR].

Please read the information below and check one box. Please sign and return this permission form by __________.

[PLEASE PRINT] Child's name: ___________________________________

I have read this form and understand it.

[ ] I GIVE PERMISSION for my child to take part in an interview and two surveys for this study and for RTI to receive information on my child’s age, race and ethnicity collected by [PROGRAM NAME].

[ ] I DO NOT GIVE PERMISSION for my child to take part in this study.

[PLEASE PRINT] Parent/Guardian name: ________________________________

Parent/Guardian signature: ________________________________

Date: ________________________________

KEEP THE FIRST TWO PAGES OF THIS PERMISSION FORM.

NOTE: The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to test ways of asking those served by healthy marriage and relationship education programs about their relationships. 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. The OMB control number for this collection is XXXX-XXXX and it expires on XX/XX/XXXX.

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