Parental Consent for Minor

Attachment 5. Focus Group Parental Consent Form (minor students)

DCPS Student Focus Group Discussion

Parent Consent Form (for Youth Less than 18 Years of Age)

Purpose of Focus Group

The Centers for Disease Control and Prevention’s Division of Adolescent School Health is working with District of Columbia Public Schools (DCPS) to hold focus groups with students to learn more about school-based sexual health services, including access to and use of the school-based health center, sexually transmitted disease testing, and condom availability. A focus group is a small group of people who come together and talk about a specific topic. We would like to get students’ general opinions about what makes it easy or hard to access school-based health centers and sexual health services at school. We will NOT be asking about your child’s own behavior or personal use of services. Information from the focus groups can help DCPS improve student access to services in the future.

ICF, a private company, was hired to conduct the focus groups. All students enrolled in classes specified by school administrators have been invited to be in a focus group. Of those, 48 students from 4 high schools will be selected to be in a focus group. The focus group will not interfere with your child’s instructional time. The focus groups will last about 90 minutes and will be held outside of school hours. Male students will be in a separate focus group from female students. Students will be asked questions regarding their thoughts and views of student access and use of school-based health centers and other sexual health services. Please note: We are not providing transportation, so if you are willing to let your child participate, you and/or your child will need to arrange a way home from the focus group. Should your child be selected to participate, advanced notice will be given with the day and time of the focus group to help with planning.

Possible Risks to Students

Being in the focus group is expected to cause no harm to your child. However, some questions may make your child uncomfortable. Your child may choose to not answer any question or to stop participating at any time.

Privacy

If your child is selected for the focus group, we will protect your child’s privacy. Your child’s name will not be on any focus group notes or reports. Focus groups will be audio-recorded to help keep track of what is discussed, but names will not be used and all records (such as this consent form) will be kept private. Your child’s participation is completely voluntary. He or she can stop at any time or skip any question that he or she does not want to answer.

However, if your child decides to share voluntary information that is subject to mandatory reporting laws, project staff will work with the school staff and the youth to make the report to authorities. Although none of our questions will ask students specifically about these topics, there are some times when we cannot promise to keep information private. For example, if your child tells the moderator that he or she plans to hurt him/herself or someone else, the moderator will have to tell someone that can help. Also, if your child is a minor (under 18 years old) and talks about having sex with a non-minor, this would have to be reported. Moderators also have to obey laws about reporting child abuse and neglect to authorities. Child abuse means someone hurting your child’s body, forcing your child to do something that hurts him or her, or leaving your child with no place to live, or no food or things he or she needs to be safe and healthy.

It is Voluntary

Being in the focus group is up to both you and your child. You may choose for your child to not take part. This will not affect class grades and no one will hold it against you or your child. Even if you allow your child to participate, your child may decide for him or herself to not to be in the focus group or to stop at any time. If your child participates in the focus group, he or she will receive a gift valued at $30 as a thank you. If your child decides to leave the focus group before it is over, he or she will still be given the gift.

Potential Risks and Benefits to Taking Part

There are minimal risks to being in the focus group. If your child is selected to take part in the focus group, his or her feedback could help DCPS find ways to improve student access to sexual health services. This has the potential to impact the overall health and well-being of students.

Questions

Parents please be aware that under the Protection of Pupil Rights Act. 20 U.S.C. Section 1232(c)(1)(A), you have the right to review a copy of the questions asked of or materials that will be used with your students. If you would like to do so, you should contact Thearis Osuji, ICF Project Manager, at 404-321-3211 to obtain a copy of the questions or materials. If you have any questions about the focus group or your rights, you may call the ICF Institutional Review Board by phone at 877-556-2218 or Thearis Osuji, ICF Project Manager, at 404-321-3211.

Please read below and check “YES” or “NO” if you do or do not allow your child to take part in the focus group. Then, sign, remove this page, and return it to the school within 7 days. The first page of this form is yours to keep.

I have read this form and know what the focus group is about.

[ ] YES, I allow my child to take part in the focus group, and if selected I understand that I must provide transportation from school on this day.

[ ] NO, I do NOT allow my child to take part in the focus group.

Parent/Guardian Name (Print):

Parent/Guardian Signature:		Date:

Student’s Name (Print):

Student’s Age:

Student’s Grade

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