[NCIPC] Youth Audience Message Testing of Substance Use Prevention Messages

OMB No. 0920-1154

Expiration Date 3/31/2026

GenIC Clearance for CDC/ATSDR

Formative Research and Tool Development

Youth Audience Message Testing of Substance Use Prevention Messages

Attachment 3 – Youth Assent Form

Contact: Jasmine Kenney, MPH

Communication Branch

Division of Overdose Prevention (DOP)

National Center for Injury Prevention and Control (NCIPC)

Centers for Disease Control and Prevention (CDC)

4770 Buford Hwy NE, MS S106

Atlanta, Georgia 30341

Phone: 770-488-5423

Email: [email protected]

Youth Audience Message Testing of Substance Use Prevention Messages

YOUTH ASSENT FORM

FOR PARTICIPANTS AGES 13–AGE OF MAJORITY

Sponsor / Study Title:	Centers for Disease Control and Prevention (CDC) / “Youth Audience Message Testing of Substance Use Prevention Messages”
Protocol Number:	11815-JRKenney
Principal Investigator:	Jasmine Kenney
Primary Contact:	Everett Long, PhD
Telephone:	704-657-5338
Address:	Fors Marsh Group LLC 4250 N. Fairfax Dr. Suite 520 Arlington, VA 22201

Note: If you are the parent or legal guardian of a child who may take part in this study, your permission and the permission of your child will be needed. When “you” appears in this form, it refers to your child except where it says otherwise.

CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

You are being asked to participate in an online journal about drug use and drug overdose prevention as part of a research study. The purpose of the online journal is to understand your thoughts, feelings, and perceptions about drug use prevention and mental health messages. This form explains the study. After reading this form, you can decide to be in the study, or you can decide not to be in the study. Either choice is OK. If you decide to join the study and then change your mind, you can stop being in the study at any time.

Please ask the study staff to explain anything you do not understand. They will answer all the questions you have. You can ask questions about the study at any time. You must sign and date this form before you can take part in the study.

Introduction: About this study

The goal of this study is to gain insight into youth perspectives on drug overdose prevention and mental health messages.

Fors Marsh is a private company conducting research on behalf of the Centers for Disease Control and Prevention (CDC) to understand youths’ thoughts, feelings, and perceptions about drug use prevention and mental health messages. What we learn will inform content development and strategy for CDC’s educational campaign to prevent drug overdose among youth ages 13–17.

What will I do during this study?

During the study, you will be asked to participate in four online activities. The four online activities will ask you questions about your awareness, thoughts, and feelings about the topics of drug use, mental health, and messages about these topics. The messages will be presented in various ways, including but not limited to written, graphic, video, or audio form.

Each online activity will last about 45 minutes, for an estimated total participation time of up to 180 minutes (3 hours). You will have up to 2 weeks to complete the activities and submit your answers. You will not have to answer any questions that you do not want to and can leave the study at any time. If you leave, you will only be paid for the activities you have completed.

What good comes from my participation?

There is no direct benefit to you for being in this study. You may learn about resources and information related to drug use prevention and mental health. You will contribute to the creation of a government sponsored campaign that will reach youth nationwide to reduce substance use and drug overdose deaths among young people.

What will I get for being in this study?

You will receive up to $250 as a token of our appreciation for participating in this study. The final total amount will be based on how many activities you have fully completed. You will be paid at the end of your participation in the research study.

Costs

There will be no cost to you for participating in this study.

Could anything bad happen to me during this study?

The risks for taking part in the study are low. You will be asked to discuss your thoughts and feelings about drug use and mental health, which could cause distress or discomfort. You do not need to answer any questions that you are not comfortable with.

We will take care to protect the information you provide. However, as with all studies, there is a chance that privacy could be broken because of an accidental error or a security breach. If a breach occurs, all participants will be notified as to the extent of the breach, any damages incurred, and future potential risks. Contact information for additional questions will also be provided.

There may be other study risks that are still unknown.

Privacy: Who will see the results of this study?

Only the authorized study staff will have access to your responses. Some personal information, like your first name and last initial, will be gathered, but no personal information will be kept after you complete the project and after you have received your incentive. Your name will not be linked to what you say. We will be very careful to only let people working on the study see the responses you provide; your responses will not be linked back to you. Your responses will not be shared with your parent(s) or legal guardian(s). Everything you share will be kept private to the extent allowed by law. This means that we will not share any information you provide with anyone outside the study unless it is required to protect you or it is required by law.

However, if you show a direct threat of harm to yourself or others, we have the right to act out of concern for your safety and the safety of others. This includes reporting any information about self-harm to your parents or caregivers.

All of the information we collect, including your responses and data collected during screening, will be de-identified (your name or personal information will be removed). The information will be kept for up to two years. The information will be stored on a password-protected computer and/or in locked cabinets that only the study staff can access. The data saved will not contain any information that could identify you. After two years, the collected data will be destroyed by shredding documents or permanently deleting electronic information.

Results from this study may appear in professional journals or at scientific meetings. No individual participants will be identified or linked to the results. We will not disclose your identity in any report or presentation. Results may also be used in future research or shared with other researchers. Other researchers will not have your name or any identifying information.

An Institutional Review Board (IRB) has reviewed this research. An IRB is a group of people who are responsible for making sure that the rights of participants in research are protected. The IRB may review the records of your participation in this research to ensure that proper rules were followed.

Participation and Withdrawal: Do I have to be in this study? What if I want to stop participating?

This study is completely voluntary. You can stop at any time. You also do not have to answer any questions that you do not want to.

If you would like a copy of this form, you can ask study staff for a copy.

Yes, I agree to participate in this study. I have read, understood, and had time to consider all of the information above. My questions have been answered and I have no further questions.

No, I do not agree to participate in this study. I have read, understood, and had time to consider all of the information above. My questions have been answered and I have no further questions.

Statement of Assent

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Printed Name of Youth Participant

__________________________________ ___________________

Youth Assent Digital Signature Date

__________________________________

Printed Name of Parent/Legal Guardian