Attach G Interview Consent-Seed

(OMB Control # 0970-0356, Expiration Date 01/31/2015)

Attachment G: Interview Consent - Seed

COLLEGE OF ARTS AND SCIENCES
Department of Sociology

201 Benton Hall
P.O. Box 880623
Lincoln, NE 68588-0623

SOP Data Collection Project [Personal Interview]

(402) 472-5562
FAX: (402) 472-4983
Toll Free: 1-888-567-5285

University of Nebraska-Lincoln
Les Whitbeck, Principal Investigator
201 Benton Hall
Lincoln, NE 68588-0623
Phone: 402-472-5562
Fax: 402-472-4983

E-mail: lwhitbeck2@unl.edu

PARTICIPANT INFORMED CONSENT FORM
This study is sponsored by money from the Family and Youth Services Bureau (FYSB) and is being
conducted by [AGENCY NAME] in cooperation with the University of Nebraska-Lincoln.
The goal of this study is to find out how we can best help runaway and homeless young people. We want to
know what kind of experiences homeless young people have had. We will use this information to identify the
services that will best help young people who do not have a regular place to live.
If you are between the ages of 14 and 21 and don’t have a regular place to live right now, we would like to
ask you to be part of our study. Whether you say yes or no will not make any differences in the services you
can get from any service agency.
If you want to participate in this study we will want to interview you. There will be one interview which will
take 1.0 – 1.5 hours. You will receive a $20 gift card for finishing the personal interview. You will also be
given three coupons to hand out to other homeless or runaway young people you know. We will reimburse
you with a $10 gift card for each person who turns in a coupon you gave them and completes an interview by
_____/_____/_____. You can pick up these $10 recruitment gift cards at [AGENCY NAME], one month
after your scheduled interview.
During the interview someone will ask you questions and enter your answers into a computer. You will be
asked questions about your family, where you have been staying, why you left home, and what has happened
to you since you haven’t had a regular place to live. You will also be asked about things like your feelings,
your daily activities, and how your life is going. Some questions are about sensitive topics, like drugs, sex,
and gang activity. You may refuse to answer any questions that make you uncomfortable.
Some of the questions may bring back bad memories or make you feel sad, but you don’t have to answer
questions that you don’t want to. You can stop the interview any time you want, but you won’t receive the
$20 gift card unless you participate in most of the interview (at least 30 minutes).

Participant’s Initials: __________

(OMB Control # 0970-0356, Expiration Date 01/31/2015)

Privacy
Everything you tell me will be private. The people who see your answers will not know your name, they will
only see an ID number. Any forms you sign, like this consent form, will be kept in a locked file away from
your interview answers. The only people who will have access to both your name and answers will be UNL
staff. Although the information you provide will be private, there are three things that the interviewer is
required to tell someone else about, including your caretaker and/or public agencies.
1. Any case of suspected physical or sexual abuse and/or neglect of children must be reported to
Child Protective Services. This may be yourself or a sibling or someone you know that you tell us
about.
2. If you tell me you are going to hurt yourself badly, or I think you might try to kill yourself, I will
get help for you. If the researchers have very serious concerns, they will need to report the
situation to the appropriate authorities.
3. If you say that you are aware of serious harm that may be done to someone else, the interviewer is
required to take steps to protect that person, which includes reporting the situation to the
appropriate authorities.
Your answers to the questions in the personal interview will be entered into a computer program by the
interviewer. Your answers will not be identified by name, only by an ID number. With your permission, the
interviews will be audio recorded and transcribed or typed to text files for analysis. The audio recordings will
not be identified by name. The audio files will be stored on secure computer servers at the University of
Nebraska-Lincoln while we work on this project and will be transcribed and securely stored only until we
have finished the study. Upon completion of the study, the files will be destroyed.
If you withdraw (or are withdrawn) from this study, any information collected up to the point of withdrawal
for the purpose of this research may still be used in order to protect the integrity of the information collected.
Risks and Benefits
Known risks include questions regarding sexual activity, victimization, and trauma. We have incorporated
four protocols to minimize risks to you: 1) The most sensitive questions will be given in a self-administered
questionnaire which you will complete directly on the computer, 2) You will be given a referral card that
includes meal, shelter, health and mental health resources in your city, 3) If at any time the discussions bring
up memories or thoughts that create distress, you may refuse to answer the question or end the interview, 4) If
you feel upset during or after a session, please let the interviewer know and he or she will contact a staff
person at [AGENCY NAME] to help you.
The benefits from participating in this study are: 1) You will be providing important information that will
help agencies develop and sustain programming specific to homeless youths’ needs, 2) You will be able to tell
your stories and share your life experiences with the interviewers, 3) You will be able to provide information
regarding the unique needs of homeless youth in your community, 4) Interviewers will provide you with
referrals for food, housing, health, and mental health programs in your community.
Voluntary Participation
You do not need to participate in this study. You may stop the interview at any time and ask that your
contributions be deleted from the transcriptions and never used without adversely affecting your relationship
Participant’s Initials: __________

(OMB Control # 0970-0356, Expiration Date 01/31/2015)

with the facilitators, project administrators, or your community. If you decide you do not want to be part of
this study, you will not have any services taken away.
Contact Information
This study is completely voluntary and it is your choice to decide whether or not you would like to be
involved. You may ask any questions concerning this research and have those questions answered before
agreeing to participate or at any point during the study. If you have any additional questions of concerns, you
may call the principal investigator, Les Whitbeck, telephone (888) 567-5285. If you have questions about
your participation in this study that have not been answered by this individual, or to report any concerns, you
may contact the University of Nebraska-Lincoln Institutional Review Board, telephone (402) 472-6965.
Interview Informed Consent
SOP Homeless Youth Project
Your signature on this form indicates the following:
 I agree to participate in the SOP Homeless Youth Project.
 I agree to have my interview audio recorded for this study.
 I understand that I will receive a $20 gift card for completing the personal interview and a $10 gift
card for each person (up to three) who turns in a coupon I gave them and completes an interview
by ____/____/____.
 I understand that all information you provide will remain private and the audio recordings will be
destroyed after the study has ended.
 I understand that participation is voluntary and I may stop the interview at any time.
 I understand that if I stop the interview, the services I may be receiving will not be affected.
 I know that if I have any questions about this study I can talk with someone at the agency where I
was interviewed and they will answer my questions.
 I agree to the study’s purpose and my involvement.
 I do not give up any of my legal rights by signing this form.
If you are not sure you understand everything we just read, I will be happy to answer any questions you have
now, or I can give you some time to talk to agency staff before you decide. You can be in the study if you
have no regular place to live, and we aren’t worried about you hurting yourself or other people. Please feel
free to ask me any questions about the study before you sign the consent. You will be given a copy of this
consent form to keep.
____________________________
Participant’s Printed Name

____________
Date

___________________________
Participant’s Signature
I was present when this was read and I think that he/she understood everything and has agreed to participate
in the study.
_____________________________
____________
Staff Signature
Date
Participant’s Initials: __________