Example - consent

Attachment 9: Sample Informed Consent Language

Online Survey Informed Consent

Purpose of the survey: San Francisco Public Schools is participating in a project funded by the Centers for Disease Control and Prevention’s (CDC), Division of Adolescent and School Health (DASH) related to sexual health and social services, referrals, and school climate and safety. This project focuses on meeting the needs of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth and, in particular, males who identify as gay or bisexual, or engage in sexual activities with other males. ICF International, a research and evaluation firm, is helping the district to better understand the impact of the project activities. As a staff member of one of the high schools in which this project is being implemented, you are being asked to help us learn about your school district. A total of 735 school staff across 3 funded school districts are being asked to participate in this survey. The survey contains questions about LGBTQ students’ experiences at school, bullying, referral practices, partnerships with community organizations, professional development, and school policies.

What you will do: You will use a computer to fill out a Web-based survey. The question will indicate whether to select only one or more than one answer. You will not be asked to provide your personal information, and your survey responses will not be linked with your personal information.

Time needed: The survey should take about 20-25 minutes to complete.

Possible risks: Answering some of the sensitive questions may make you upset or uncomfortable. The survey is voluntary and you may choose to discontinue at any time for any reason. You will not be asked to enter your name on the survey, and you will not be asked for any personal information like your address. Your responses will not be attributed to you so no one will know what you said. School-level data will be presented in aggregate, not at the individual level.

Benefits: Answering these questions will give you the chance to share information about your work, student experiences at school, providing referrals to students, the climate in your school, policies and practices, and professional development you may have had. By sharing your experiences, you will contribute to the improvement of the services for youth, particularly LGBTQ students, at your school.

Deciding not to take the survey: Taking this survey is completely voluntary. You can choose to take it or not to take it. If you choose to take the survey, you can stop the survey at any time.

If you decide not to take the survey, or decide to stop answering the questions at any point during the survey, it will not be held against you in any way. Other staff and administrators at your school will have no knowledge of your decision to participate or not participate.

Contacting the evaluator: You may call Catherine Lesesne from ICF International at (404) 592-2230 if you have questions about this study. If you have questions about your rights related to this study, you can call the ICF International Institutional Review Board at (877) 556-2218.

Clicking “yes” below means that you agree to take the survey. If you wish to stop at any time, click the “exit” button at the bottom of the screen; you will see a box asking you if you want to save your answers or erase them. Thank you.

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

No – I do not agree to participate in the survey