Appendix H - Adolescent Informed Assent Participant Form

APPENDIX H

Childhood and Family Experiences Study

Youth (12-17) Assent Form

PARTICIPANT COPY

We are doing a study about families and their money situation.

If you agree to be in our study, I’ll start by asking a few questions about yourself, like what grade you’re in (if you are still attending school) and what some of your favorite things are, and what your life is like. For example, I have some questions about how much money your family has and if your family members talk with you about money. Other questions ask about your ideas about the amount of money that other people have, such as why some people have a lot of money while others have very little money.

Answering my questions is voluntary; it’s up to you. If you don’t feel like answering a question, just tell me and we will skip it and go on to the next question. If you decide you don’t want to do any more, please tell me and we can stop at any time. It is O.K. to tell me that you want to skip a question or stop. You can also let me know if you don’t understand a question so that I can repeat it or ask it a different way.

Although the interview if voluntary, we hope you will be interested. Your opinions and ideas will help researchers and people who make policy decisions understand how children and youth feel about these matters.

Your name will not be on any of the answer sheets, so no one will know how you answered these questions. Instead, my answer sheets will have a number on them. Only the people I work with will be able to see the answer sheets I use today. We also have a special thing called a Certificate of Confidentiality from the U.S. government. This means we will not tell anyone what you tell us even if a judge or a court asks for it. The only time we will say anything is if the law says we have to say something. For example, if we are worried that you or someone else is in danger. If you tell us that you or someone else is getting hurt or may get hurt, we will tell people who are responsible for protecting children and teenagers.

If you agree to answer my questions today, at the end of the interview you will receive a $25 gift card as a thank you. Even if you choose not to answer some or any of my questions, you will still get a gift card.

INTERVIEW AUTHORIZATION

When I sign my name here I am saying that the information on this page has been read to or by me, and I agree to be interviewed for this study. I am also saying that I understand what I am being asked to do and that I may stop the interview at any time.

YOUTH’S NAME: __________________________________________ DATE __________

BIRTHDATE _____________ ______

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Youth’s Signature Date

AUDIO RECORDING AUTHORIZATION

When I sign my name here I am saying that the information on this page has been read to or by me, and I agree that the interviewer can use an audio recorder to record the conversation. I am also saying that I understand what I am being asked to do and that I may stop the interview at any time.


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Youth’s Signature Date

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This collection of information is voluntary and will be used to understanding the families’ experiences with money. Public reporting burden for this collection of information is estimated to average 53 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Sam Wulfsohn at MDRC via e-mail at [email protected].