1455 Parent Consent Form

OMB Control Number: XXXX-XXXX

Expiration Date: MM/DD/YYYY

Parent/Guardian Consent Form (Computer Screen)

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control number. The OMB Control Number for this information collection is XXXX-XXXX (expiration date: MM/DD/YYYY). Public reporting for this collection of information is estimated to be approximately 3 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave. SE, Washington, DC 20590.

The Traffic Injury Research Foundation (TIRF; www.tirf.ca), on behalf of the National Highway Traffic Safety Administration (NHTSA; www.nhtsa.gov), is conducting a research study to help improve the safety of young drivers. To assist us with the study, we are looking for teen volunteers to participate. Your State DMV identified your teen as eligible to participate in this study and provided us with contact information (your teen’s name and street address).

In the study, your teen will be asked to:

• Provide their driver’s license number so that their driving record can be included in the research results (the information your teen provides us will be used for research purposes only);

• Complete a 45-minute online driver training program for which they will be mailed $5 for helping us.

Some teens will also be asked to:

• Complete a week-long driving diary to record their trips each day for 7 days, for which $10 will be mailed to them;

• Complete a follow-up 15-minute online driver training program after six months, for which an additional $10 will be mailed to them.

There are no known direct physical or psychological risks to participating in this study. Risks to your teen’s personal information (name, address, driver’s license number, driving record) are minimal. Your teen’s driver’s license number will be used only to obtain their driving record for research purposes. We will assign a unique ID to each participant. We will use that ID to identify your teen’s study data, including crash and citation information. Your teen will not be identified by name or driver’s license number, only by that unique ID.

We will store all personal information collected from your teen separately from his or her study data, which will be identified by participant number only. The study data will consist of your teen’s online driver training program results and the number and types of crashes and citations over the study period. Once the invitation to participate in the follow-up study has expired, or once we send your teen compensation for participating in the study and TIRF has received your teen’s driving record, we will electronically delete your teen’s personal information from our computers. Additionally, we do not create or keep paper records of your teen’s personal information.

Participation in this study is completely voluntary and will not affect your teen’s relationship or standing with your State’s licensing authority. Your teen will not get into trouble for any road safety information obtained as part of this study. Your teen can decide not to participate in this research study at any time for any reason and has the right to refuse to answer any individual question without penalty or loss of compensation.

Only the researchers involved in this study and the research sponsor (NHTSA) will have access to the information your teen provides, both during and after the study. All study data will be stored electronically on secure computers. By consenting to have your teen participate in this study, you are giving us permission to use your teen’s study data in scientific presentations and publications. You are also giving the study sponsor, NHTSA, the right to use the data for educational, research and outreach purposes. However, we will ensure that no published reports include your teen’s name, address, driver’s license number, driving record, or study results. Your teen’s results will not be shared with any licensing authority. All study results will be published only in the form of summary statistics that cannot be used to identify your teen’s individual responses.

Although this study may not directly benefit your teen, we hope that the knowledge that NHTSA and the traffic safety community gain will help to enhance driver education programs and the road safety of teen drivers. If you would like to verify this study, the OMB Control Number for this information collection is XXXX-XXXX (expiration date: MM/DD/YYYY).

If you or your teen have any questions about this research study, please contact Steve Brown at [email protected], or call us toll-free at 1-877-238-5235. If you have questions or concerns about your teen’s rights as a participant, you may contact New England’s IRB office at 1-800-232-9570.

___ Click here to acknowledge you have read the above and agree to your teen proceeding with the study.

Please enter your name: ____________ (First) _____________________(Last)

NHTSA Form 1455