Att 12_Example Adult Consent Form

Attachment 12

Example Adult Consent Form

Informed Consent Form

Purpose of the study: Your child’s school district is a part of an HIV- and STD-prevention project funded by the CDC’s Division of Adolescent and School Health. This project includes activities to help parents become more engaged in their children’s health issues, including HIV and STD prevention. We are helping the district to learn the impact of this project. The school district identified parents who could tell us more about their perceptions related to HIV and STD among youth as well as their own interactions with their children. You have been selected to be in a group of 200 parents who will provide this type of feedback via a survey. This survey asks some general questions about your perceptions of your child as well as about your communication with your child about HIV, STD, and pregnancy prevention as well as your perceptions of access to health care.

What you will do: You will use a computer to fill out a Web-based survey.

Time needed: The survey should take less than 25 minutes to complete.

Possible risks: There are no known risks associated with taking this survey. Taking this survey is voluntary. You may stop taking the survey at any time for any reason. Your responses will not be linked with your name or your child’s name. Participant names will not be included in any reports.

Benefits: If you take this survey, it will give you the chance to share information about your child and your engagement with your child. By taking this survey, you will help inform the services offered to students in your school district and their parents.

Deciding not to take the survey: Taking this survey is voluntary. You can choose to take it or not to take it. If you choose to take the survey, you can stop at any time. If you decide not to take it, or decide to stop answering the questions at any point during the survey, it will not be held against you or your child in any way. No one at the school will know who participated or declined to participate.

Persons to Contact: If you have any questions about how the study works, you can contact [name of principal investigator] at [contracting agency or CDC] at ­[phone number and email address]. If you have any concerns about your rights in the study, you can call the Institutional Review Board at [phone number].

I have read the informed consent statement and agree to participate in the survey.

Printed Name: _________________________________________________

Signature: _____________________________________________________ Date:_________________