1 CTK Youth Assent Form

OMB Control No: 0970-0401

Expiration date: 10/1/2020

Youth Focus Group

Youth Assent for Participation in a Focus Group

____________________________________________________________________________________Public reporting burden for this collection of information is estimated to average less than 5 minutes per response, including the time for reviewing instructions and providing the information requested. You are not required to respond to any request for information unless it displays a currently valid OMB control number.
________________________________________________________________________________­­­­____

Introduction and purpose:

RTI International is a nonprofit public health organization headquartered in Research Triangle Park, NC. RTI provides health research and technical services to government and commercial clients worldwide. RTI is conducting a series of focus groups with youth to guide a project we’re leading to help youth stay healthy and achieve their goals. The purpose of our project is to design a marketing campaign, game, and website for youth ages 10 – 22 that will empower them to make informed choices to help them avoid risky behaviors. With this focus group, we hope to understand what types of content, products, and design elements are most appealing to people your age.

We will not collect any personal or family health information from you. This activity is not considered research with human subjects. Researchers at RTI are conducting this project and activity using public funds. None of the researchers participating in this study stand to gain anything financially or personally.

This form requests your assent to participate based on what the project is about and what you will be asked to do. It also tells you how we will protect your information and who you can call if you have questions. Please ask the researcher to explain anything you do not understand. Your parent was provided with a parental permission form with similar information about the study, and provided their permission for you to participate.

Procedures:

If you agree to participate, you will take part in a one-time, [insert “in-person” or “virtual”] focus group. The discussion will last approximately 60 minutes. The session will take place at the [insert physical location or virtual information].

During the focus group, you and up to 9 other youth will complete activities such as reviewing concepts for social media posts, ranking messages and risky behaviors, and providing general feedback on language for social media posts. An experienced moderator will conduct the activity. We are audio-taping this conversation for note-taking purposes only; the recording will be delivered immediately after completing the notes.

Risk/Discomforts:

There are minimal risks to you for participating in this study. There are no costs associated with taking part in this study.

1. While the discussion questions we ask are not meant to be sensitive, there is always a chance that you may feel uncomfortable with some of the questions. You do not have to answer any question that you don’t want to answer. You can stop participating at any time. Your participation is completely voluntary.

2. RTI will take several steps to keep your participation confidential and will not share your name with anyone outside of the session. The information that you give us will be anonymized and combined with the responses of other participants to inform our campaign design. All notes taken during the activity will be kept in a locked file cabinet or on a password-protected computer. Only authorized project staff will be able to see them.

Benefits:

This study will offer you $15 in the form of a gift card as a token of appreciation for your time and effort. [For grantees who request that incentives not be offered, replace this statement with: This study will provide no direct benefit to you, although you may find the session fun and interesting.]

Right to Refuse or Withdraw:

It is your choice to be in this focus group. You can choose not to talk about any topic. You can stop participating in the session at any time without penalty.

Persons to Contact:

If you have questions about the project, you can call the Project Director, Dr. Barri Burrus, at 1-800-334-8571 ext. 25109 (a toll-free number). If you have questions about your rights as a participant, you can call RTI’s Office of Research Protection at 1-866-214-2043 (toll-free number).

STATEMENT OF ASSENT FOR THE FOCUS GROUP

I have read this assent form. The above document describing the benefits, risks and procedures for this focus group has been explained to me. I had a chance to ask questions, and my questions were answered. I was given a copy of this assent form.

Do you assent to participate in the study now?

___ Yes ___ No

__________________________________ ________________

Participant Signature Date