OMB Number: 0970-0531 [Insert logo here]
Expiration Date: XX/XX/XXXX
INFORMATION SHEET AND CONSENT FORM FOR VOLUNTARY PARTICIPATION
Adult Staff Who Are Lesson Facilitators
Sponsored by the U.S. Department of Health and Human Services
INTRODUCTION
The Administration for Children and Families (ACF) is part of the U.S. Department of Health and Human Services. ACF is working with Mathematica, an independent research organization, to test two lessons from the Digital Citizenship curriculum. Digital Citizenship is an Internet safety curriculum developed by Common Sense Education and Project Zero at the Harvard Graduate School of Education. The two lessons being tested were adapted for youth with intellectual and developmental disabilities. The lessons help youth navigate online interactions and build healthy and rewarding friendships both online and off. [IMPLEMENTING ORGANIZATION NAME] is taking part in the study.
WHAT IS THE STUDY ASKING ME TO DO?
We are asking you to teach the two lessons to youth in your class. We are also asking you to do the following activities so we can understand how the curriculum was implemented and obtain your feedback about the lessons.
Participate in a classroom observation of one implementation session.
Complete an online fidelity log after each implementation session (at least two logs).
Participate in a 1-hour interview after the lessons have been completed.
HOW WILL THE STUDY KEEP MY INFORMATION PRIVATE?
If you choose to take part, we will group your answers to the questions with the answers from other lesson facilitators. Your name will not be attached to the answers you give.
With your permission, we will audio-record the interview. If you do not agree to audio-record the discussion, you can still participate without being recorded. The recording will be destroyed after we have checked our written notes. We might share recorded answers with outside partners to transcribe notes, but no names will be attached.
ARE THERE ANY BENEFITS TO BEING IN THIS STUDY?
While there is no direct benefit to you or your students, you will be helping with the development of lessons about Internet safety for youth with intellectual and developmental disabilities.
ARE THERE ANY RISKS TO BEING IN THIS STUDY?
The only risk to you is that you might be uncomfortable answering some questions. You do not have to answer any questions that you do not want to answer. You may also stop participating in the discussion at any point. There are no right or wrong answers to our questions.
DO I HAVE A CHOICE ABOUT BEING PART OF THIS STUDY?
You and have a choice whether to be part of this study. There are no penalties or consequences for not taking part. You can also choose not to answer our questions or may stop taking part at any time.
WHEN IS THE STUDY TAKING PLACE? HOW LONG WILL IT LAST?
The lesson facilitation and study activities will take place in the spring and summer of 2022. We will work with you and/or your school to determine a timeframe for these activities.
WHAT IF I HAVE QUESTIONS OR COMMENTS ABOUT THIS STUDY?
If you have questions, concerns, or complaints about the study, please call Katie Adamek at 1-617-583-1940.
If you have questions about your rights as a research volunteer, if you think the research negatively affected your child, or if you have other questions, concerns, or complaints, contact HML IRB at 1-202-246-8504.
WHAT DO I DO NEXT?
Please let us know whether you will participate by signing the consent section below. Return it to [Katie Adamek at Mathematica/Name of contact at implementing organization].
Sincerely,
Jean Knab, Ph.D.
Project Director
Mathematica
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Lesson Facilitator Study Consent
Sponsored by the U.S. Department of Health and Human Services
I have read the information sheet describing the lessons that I will teach and the related study activities. I understand that I can choose to be part of this study or not. I also know that I may stop being part of it at any time. I will not be penalized for choosing not to be part of it. By signing this form, I am agreeing to participate in all parts of this study.
Signature: ____________________________________________ Date: _______________
Type name: ___________________________________________
Approved by [IRB] on XX-XX-XXXX
[IRB] Version 1.0
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Melissa Thomas |
| File Modified | 0000-00-00 |
| File Created | 2022-07-14 |