Final 1-18-23-Appendix G_Child Assent Form_FINAL

OMB Clearance Number: 2528-0259
Expires: XX/XX/XXXX

The Family Options Study
APPENDIX G: Child Assent Form – Children 10-17 years old

Purpose (What is this about?)
I work for a company called Abt Associates. Abt is located in Rockville, Maryland. We are trying to learn which kinds of housing and services help children and families the most. We are interested in learning more about how you and other people your age feel about different things. You may remember completing a short interview or playing a game with one of my coworkers a long time ago.

What are we asking you to do?
We would like to ask you some questions about personal feelings and school. The questions will take no more than 30 minutes to answer. Your parent(s) have said it is okay that you answer these questions. Even though your parents said yes you can participate, you can decide whether you want to answer these questions or not.

There are no right or wrong answers to my questions. I am interested in your ideas and opinions. The information the researchers learn may help you or other children and families in the future.

Can you say “No”?
Yes. You do not have to answer any questions you do not want to. Some of the questions may make you sad or embarrass you a little. If you do not feel like answering a question, that’s okay. We can just skip that question and go onto the next one. If you don’t want to answer any more questions, please tell me. We can stop the interview at any time. No one will be upset with you if you say “no” or if you say “yes” and then change your mind. Remember, if you have any questions about the study, just ask me.

Protecting your information.
Your answers will be kept private. Any information that the researchers collect about you will be kept private.

Your family members won’t be able to hear what we’re talking about and I won’t tell them any of your answers. Please be honest when you answer the questions. We will keep your information private. We will not share your answers with your parents.

We will do everything we can to make sure other people don’t know that you participated in this study. We have a certificate from the U.S. government that adds special protection for the information that identifies you. It doesn’t mean that the government thinks that our project is a good idea or not. It does say that we do not have to identify you, even if a judge asks us to. But, if we hear that you or someone is at risk of getting hurt, we may tell someone else to keep you and others safe.

At the end of the study, Abt staff will give all data collected to the government agency that paid for this study, the U.S. Department of Housing and Urban Development or HUD. HUD will also keep your information private.

Statement of Assent

I have read this form, or had it read to me. I know that any information I provide will be kept private, unless someone is at risk of getting hurt. I understand that my parent gave permission for me to participate in this survey. I know that I can choose not to participate in the interview but if I do participate in the interview, I can refuse to answer any questions or stop the interview at any time without penalty. I understand that my parents will not see my answers. By checking the box below and signing this form, I am agreeing to participate in the study.

Yes, I want to participate in this study____

No, I do not want to participate in this study____

Printed Name of Child ____________________________________

Signature of Child __________________________________

Date __________________

Printed Name of Interviewer __________________

Signature of Interviewer Date __________________

COMPLETE IF INTERVIEW COMPLETED BY PHONE:

Verbal Consent Obtained: YES NO

DATE: ________________________

_____________________________________ __________________________________

Name of Interviewer Signature of Interviewer