1 CTK Parent Consent Form

OMB Control No: 0970-0401

Expiration date: 10/1/2020

Youth Focus Group

Parental Permission for Your Child’s Participation

____________________________________________________________________________________Public reporting burden for this collection of information is estimated to average less than 5 minutes per response, including the time for reviewing instructions and providing the information requested. You are not required to respond to any request for information unless it displays a currently valid OMB control number.
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Introduction and purpose:

RTI International is a nonprofit public health organization headquartered in Research Triangle Park, NC. RTI provides health research and technical services to government and commercial clients worldwide. RTI is conducting a series of focus groups with youth to guide a project we’re leading to help youth stay healthy and achieve their goals. The purpose of our project is to design a marketing campaign, game, and website for youth ages 10–22 that will empower them to make informed choices to help them avoid risky behaviors. With this focus group, we hope to understand what types of content, products, and design elements are most appealing to youth and young adults.

We will not collect any personal or family health information from your child. This activity is not considered research with human subjects. Researchers at RTI are conducting this project and activity using public funds. None of the researchers participating in this study stand to gain anything financially or personally.

This form requests your parental permission based on what the project is about and what your child will be asked to do. It also tells you how we will protect your child’s information and who you can call if you have questions. Your child will be provided with an assent form with similar information at the time of the session.

Procedures:

If you agree to let your child participate, they will take part in a one-time, [insert “in-person” or “virtual”] focus group. The discussion will last approximately 60 minutes. The session will take place at the [insert physical location or virtual information]

During the focus group your child and up to 9 other youth will complete activities such as reviewing concepts for social media posts, ranking messages and risky behaviors, and providing general feedback on language for social media posts and products. An experienced moderator will conduct the activity with the help of a note taker. We are audio-taping this conversation for note-taking purposes only; the recording will be delivered immediately after completing the notes.

Risk/Discomforts:

There are minimal risks to your child for participating in this study. There are no costs associated with taking part in this study.

1. While the discussion questions we ask are not meant to be sensitive, there is always a chance that your child may feel uncomfortable with some of the questions. Your child does not have to answer any question that they don’t want to answer and can stop participating at any time.

2. RTI will take several steps to keep your child’s participation confidential and will not share their names with anyone outside of the session. The information that your child gives us will be anonymized and combined with the responses of other participants to inform our campaign design. All notes taken during the activity will be kept in a locked file cabinet or on a password-protected computer. Only authorized project staff will be able to see them.

Benefits:

This study will offer your child as $15 in the form of a gift card as a token of appreciation for their time and effort. [For grantees who request that incentives not be offered, replace this text with: This study will provide no direct benefit to your child, although they may find the session fun and interesting.]

Right to Refuse or Withdraw:

Your child’s participation in this focus group is voluntary. Your child can choose not to answer any questions and can stop participating at any time without penalty. You may withdraw your permission and stop your child’s participation at any time.

Persons to Contact:

If you have questions about the project, you can call the Project Director, Dr. Barri Burrus, at 1-800-334-8571 ext. 25109 (a toll-free number). If you have questions about your child’s rights as a participant, you can call RTI’s Office of Research Protection at 1-866-214-2043 (toll-free number).

STATEMENT OF PARENTAL PERMISSION FOR THE INTERVIEW

I have read this parental permission form. The above document describing the benefits, risks and procedures for this focus group has been explained to me. I had a chance to ask questions, and my questions were answered. I was given a copy of this parental permission form.

By signing this form, you agree to allow your child to participate in our focus group.

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Child’s name Date

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Printed name of parent or guardian Date

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Signature of parent or guardian Date