INFORMED CONSENT FOR A MINOR TO PARTICIPATE IN A
SELF-SCREENING
AND SELF-REFERRAL PREVETION SERVICE AND SHARE DATA ANNONYMOUSLY
(11/22/21 DRAFT at Flesch-Kincaid Reading Level 7.3)
What will happen as part of this service? You are being asked to have your teen complete a screener using the Screening for Success (S4S) app and receive a report to help you identify services near you that may help.
What does the service involve? S4S will ask your teen questions about their feelings and behaviors related to your wellness, family, health, mental health and substance use. You can take see or take the screener yourself first by clicking here. The app will generate a report to identify strengths and problems. It will also help you find nearby services related to your teen’s problems.
What are the benefits to us? Taking S4S can help your family identify your teen’s needs. The report can also help connect your teen to services. Your participation may also benefit other people by helping us to improve our service. This is service is free to you. Sharing data may help us improve the service for others.
Will anyone else see your teen’s answers? It is up to your family. We will ask your teen if we can share their answers with you. We will also ask if we and other researchers may use their answers to help us improve this service. We allow you to add your teens name and contact information when inviting them. We also do allow you to give add their name when saving or printing the report. However, we do not save this information. We will remove user names to make your teen’s data anonymous before sharing. Below we will ask you the same questions. After you see your teen’s answers and report, we will also check to see if you want to change your answer.
Are there any risks to taking the S4S? There are a few risks to taking the screener. It may be uncomfortable for your teen to answer some of the questions and to share them with you. We will not share the answers with anyone else without both your teen and your permission. We and other researchers will not know who they are and will only report out answers across groups of people. It is not usually a problem, but there is a small risk that someone could gain access to the data. We try to prevent this by storing all data on a secure and encrypted server. Your username and any contact information are for you to track changes over time. They will not be exported or shared. After 2 years, we will destroy all information that identifies you or your teen. Federal law also protects your privacy.
Is this voluntary? Your family is free to decline this service. Your teen can also skip any question they do not want to answer. It is up to you teen whether to share their answers and report with you. It is up to both of you whether to share data with researchers. If you decline to share your data, you can still save the results and access the referral resources. You can also change your mind about sharing at any time.
What if I have more questions? You can send any other questions to the S4S team by calling/texting 309-000-0000 or emailing [email protected]. You can also address any concerns or suggestions to the S4S project director (Dr. Michael Dennis; phone: 309-451-7801; email: [email protected]). If you have questions about your family’s rights as a participant, you can contact Dr. Ralph Weisheit, chair of Chestnut’s Institutional Review Board for the protection of Human Participants at (309) 451-7855. You can save a copy of this document by clicking here.
PARENT
AGREEMENT (CONSENT) FOR MINOR TO PARTICIPATE IN THIS SERVICE.
This
service has been explained to me. I have been given information
about how to ask additional questions. I know we can chose not to use
the service or withdraw from it without penalty. Confidentiality of
records related to my involvement in this service will be maintained
in accordance with federal law. When required by law, the data
records may be reviewed on an anonymous basis by applicable
governmental agencies.
May we and other researchers use your teen’s answers “without their name or user name” (anonymously) to help improve this and other services? Yes No
Name of Parent (electronic signature):___________________________________ Date _______________
Name of Minor: ____________________________________________________ Date of Birth _________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | TIMELINE FOLLOWBACK CALENDAR: 2010—I assume the care manager will do this every 3 months |
| Author | ldillenb |
| File Modified | 0000-00-00 |
| File Created | 2022-07-11 |