Attachment D
Parental Consent
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Permission for Minor Teenager to Be in a Research Study
The Centers for Disease Control and Prevention (CDC) wants to know about teen health and behavior. Questions will ask about feelings and behaviors including sex and drug use. Some questions will ask about family and friends. The teen will use a computer to take the survey. It will take about 45 minutes. Please ask questions if there is anything you do not understand.
There are no direct benefits to your teen for being in this project. Your teen may feel awkward answering questions about personal matters. We have taken steps to protect their privacy. They will be given headphones to increase privacy.
If you allow your teen to be in this project, we will offer them $20 as a token of appreciation for their participation. Your teen will be offered $20 even if they do not finish.
Your teen’s answers will be kept private to the extent allowed by law. Answers will be sent to a secure system at the main study office. Your teen’s answers will not be shared outside the project. Your teen’s name will not be kept with their answers. Their answers will be mixed with other teens for reports. At the end of the study we will delete all names and addresses. The law requires us to report to the police or other authorities if you or your teen tells us about abuse. We must also report if you or your teen talk about a plan to harm yourselves or others.
It is your choice to allow your teen to take the survey. If you agree, your teen will also be given the choice to participate in this survey. They can choose not to answer any questions. They can also stop answering questions at any time. This will not affect any benefits you or your teen receives.
If your teen completes the survey, they may be contacted after the survey to ask about their survey experience. You will be given a copy of this form for your records.
You may call Chad Rodi from ICF International at (877) 736‑7911 if you have questions about this study. If you have questions about your teen’s rights as a volunteer, please contact CDC Human Research Protection Office at (800) 584-8814. Leave a message with your name, phone number, and refer to CDC protocol #6097, and someone will call you back.
I read this form, or it has been read to me, and I understand what it says. My questions have been answered. I agree that my teen, ____________________, has my permission to participate in this study.
Parent/Guardian Signature
Date
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Informed Consent – Caregiver |
| Author | Gordon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |