Appendix A: Parental consent and youth assent forms

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APPENDIX A:  
PARENTAL CONSENT AND YOUTH ASSENT FORMS, COMMUNITY SETTINGS STUDY 

This page has been left blank for double-sided copying. 
Voluntary Parent/Guardian Consent for Youth to Participate in the Community Settings Study 
Study description and purpose
This study will explore Sexual Risk Avoidance Education (SRAE) programming in community settings. The study will describe programming in these settings and share promising practices and strategies to address challenges. The study team would like to hear directly from youth that participated in the programming to understand their experiences, feedback, and suggestions. The study’s findings may help improve future programming for youth in these settings across the country. 
This is a permission form with information to help you decide if your child or a child in your care can participate in the study.
Mathematica, an independent research firm, is conducting this study for the Administration for Children and Families (ACF). ACF is an agency in the federal government within the U.S. Department of Health and Human Services that supports the health and well-being of youth. 
What will your child be asked to do? 
We are asking permission for your child (or a child you are the guardian or legally authorized representative for), to be in a 40-minute focus group. A focus group is a discussion that Mathematica staff will guide with a small group of youth that have participated in the SRAE programming offered by [provider organization name]. The focus group will take place at [location of focus group]. 
During the focus group, your child and the other youth can share their thoughts about whether the SRAE program met their needs and was relevant to them. They can also share their ideas for how the program could be improved. We will not ask your child about their own behavior. We will ask your child about their experiences with the program; we will advise your child to avoid sharing any personal or sensitive information during the focus group to protect their privacy. 
Your child’s point of view is very important for this work. 
If for some reason we cannot do a focus group, we may ask your child to do a short individual interview. The interview questions will be the same as the focus group questions.
What are the risks and benefits to participating?
    • There are no known risks associated with this study. The only risk to your child is that they might be uncomfortable answering some questions. If that happens, your child does not have to answer any questions that they do not want to answer. Your child may also stop participating in the discussion at any point. There are no right or wrong answers to our questions.
    • Your child’s participation is entirely voluntary. Even if you give permission for your child to participate, they can choose for themselves whether they want to participate or not. There are no consequences if your child decides not to participate in this research study.
    • Your child will receive a token of appreciation for participating. Your child will receive a $40 gift card as a token of appreciation for completing the focus group or interview. 
How will your child’s privacy be protected?
    • If you choose to let your child take part, we will use only first names during the discussion. While no participants’ names or feedback will be disclosed or used in identifiable form for any other purpose, your child may be in a focus group with up to seven other youth and therefore those youth will know your child participated in the group and the feedback they shared during the group. 
    • The responses your child provides will be combined with the responses from other youth participating in the study. 
    • Staff at [provider organization name] may know that your child participated in a focus group. However, your child’s responses will not be disclosed or used in an identifiable form to staff at [provider organization name]. 
    • We will audio-record the discussion so that the study team can take accurate notes. The recording will be destroyed at the end of the study. We might share recorded answers with outside partners to transcribe notes, but no names will be attached. 
    • We will keep everything your child tells us private unless we’re faced with a mandated reporting situation.  We are required by law to report your child’s name to authorities if: 
    • We suspect child abuse or neglect.
    • Your child says something that suggests they are likely to harm themselves, harm another person, or that someone is likely to harm them. 
    • All information collected will be securely stored and will not be shared with anyone outside of the study team.  
    • You can find more information on ACF’s privacy policy here: https://acf.gov/privacy-policy. 
How will the information collected from the focus group be used? 
The study team will write a report for ACF that summarizes the findings from the data collection activities. Your child’s name and responses to the focus group or interview will not be disclosed or used in identifiable form. 
Who can you contact for more information?
If you have questions about the SRAENE study, please contact Betsy Keating at [email protected] or (312) 994-1014.
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 Health Media Lab Institutional Review Board at (202) 246-8504 or by email at [email protected].
Agreement to participate
If you agree, then your child will decide on their own whether to participate. They will be asked to sign their own agreement form.





Sexual Risk Avoidance Education National Evaluation (SRAENE)
Parent, Guardian, or Legally Authorized Representative Permission Form
We need your answer, whether it is yes or no.
Please fill out the form and have your child return it to the SRAE program team.

In giving permission for my child (or a child for whom I am the guardian or legally authorized representative) to participate, I understand my child will be asked to complete a 40-minute focus group or interview. I understand participation is voluntary, and my child can stop at any time with no consequences. I also understand that all information on my child will be kept private and used only for the purposes of the study. If I have questions about my child’s rights as a study participant, I can call the Health Media Lab toll-free at (202) 246-8504. 
I have read the information sheet describing the study. By signing this form, I am saying (CHOOSE ONE): 
	Yes, I permit my child, _________________________________, to participate in the study. 
	(Print child’s name) 

	No, I do not permit my child, ________________________________, to participate in the study.                                                                    
                                                                       (Print child’s name)
	 
						 
Parent/Guardian/Legally Authorized Representative Signature: _______________________
Date: ___________________________



Youth Participation Agreement Form for the Community Settings Study 
Study description and purpose
This study will explore Sexual Risk Avoidance Education (SRAE) programming in community settings. The study will describe programming in these settings and share promising practices and strategies to address challenges. The study team would like to hear directly from youth that participated in the programming to understand their experiences, feedback, and suggestions. The study’s findings may help improve future programming for youth in these settings across the country.
This is a permission form with information to help you decide if you want to participate in the study.
Mathematica, an independent research firm, is conducting this study for the Administration for Children and Families (ACF). ACF is an agency in the federal government within the U.S. Department of Health and Human Services that supports the health and well-being of youth. 
What will you be asked to do? 
You will be asked to complete a 40-minute focus group. A focus group is a discussion that Mathematica staff will guide with a small group of youth that have participated in the SRAE programming offered by [provider organization name]. During the focus group, you and the other youth can share your thoughts about whether the SRAE program met your needs and was relevant to you. You can also share your ideas for how the program could be improved. We will not ask you about your own behavior. We will ask you about their experiences with the program; we advise you to avoid sharing any personal or sensitive information during the focus group to protect your privacy.
Your point of view is very important for this work. 
If for some reason we cannot do a focus group, we may ask you to do a short individual interview. The interview questions will be the same as the focus group questions.
What are the risks and benefits to participating?
    • There are no known risks associated with this study. You might feel uncomfortable answering some of questions on the focus group. If that happens, you do not need to answer any questions that make you uncomfortable. 
    • If you choose to participate, you will receive a $40 gift card for completing the focus group or interview. 
Do you have to participate?
No. You can choose to participate or not participate without any consequences. You can still participate in the [SRAE program name] program even if you do not agree to the study.  
How will your privacy be protected?
    • The study team will keep everything you tell us private. In reports or other summaries of the study, the study team might quote something you said but will not use your name in any of the reporting. 
    • Nothing will be shared with your parents, guardians, teachers, your facilitator at [provider organization name], or anyone outside of the study team. However, we are required by law to report your name to legal authorities if:
    • We suspect child abuse or neglect.
    • You say something that suggests you are likely to harm yourself, harm another person, or that someone is likely to harm you.
    • The study team will ask all youth in the focus group [IF PROGRAM SITE REQUIRES AN ADULT TO BE PRESENT DURING FOCUS GROUP: and program staff] to keep the information discussed private. There is a chance that someone might share what is said with people outside the group.
    • All information collected will be kept in a secure location for the study team to use, and we will destroy the information at the end of the study. We might share the recordings with outside partners to transcribe notes, but your name will not be included in the recording.
    • You can find more information on ACF’s privacy policy here: https://acf.gov/privacy-policy. 
How will the information from the focus groups and interviews be used?
The study team will write a report for ACF that summarizes the findings across all participating youth. Your name and the information you provide through the focus group will not be shared or used in any way that identifies you. 
Who can provide more information about this study?
    • The Health Media Lab Institutional Review Board has approved this work. 
    • If you have any questions or concerns, please contact Betsy Keating at [email protected] or (312) 994-1014. 
Agreement to participate
    • By signing below, you agree to participate in the focus group or interview.  
    • Your signature means that your questions have been answered, and that you have read and understood the information provided above. 
    • I accept the terms described above and will voluntarily participate in the focus group or interview for the study. 
    • I do not wish to participate in the focus group or interview for the study. 

________________________________________________________
Print your name
____________________________________	                                 _______________________
Your Signature						        Date