Att G - Student Assent Form and Parent Notification Form (v3)

Attachment G

Student Assent Form and Parent Notification Form

Student Assent Form and Parent Notification Form

Student Assent Form

Background

Dating can be a lot of fun but can also be tough when there are fights. When two people fight they can say or do things that are hurtful. Some schools offer programs to prevent bad things from happening in relationships. Often we don't know if these programs are helpful in making relationships better. Your school may or may not offer programs like this.

This research study is funded and run by the Centers for Disease Control and Prevention (CDC). CDC is a public health agency that is part of the United States government. CDC develops programs to keep young people healthy and safe.

SafePlace is the local agency that will carry out this study. Safe Place helps people who have experienced violence and works to prevent abuse and promote positive relationships. Staff at SafePlace are assisting CDC in learning how programs can be improved to help teens establish positive relationships. SafePlace staff will be involved in working with you to complete surveys about your relationships.

Purpose

Your school may or may not offer dating violence prevention programs. For the study, we would like you to complete surveys. Your responses will help us understand how students in schools with and without these programs handle relationships and conflict. This will help us understand if dating violence prevention programs are helpful to students.

Procedures

You will be asked to complete surveys about your relationships and related feelings and attitudes. This is not a test and there are no right or wrong answers. After you finish, the survey will be placed in an envelope and sealed.

You will complete 4 surveys around the following times: now/soon, in 8 months, 12 months, and 18 months. The Expect Respect facilitator will contact you at these times to ask you to complete the survey.

Potential Risks and Discomforts

Answering questions about relationships could make you feel nervous or uncomfortable. For this or any reason, you can stop participating in the study at any time. You may also talk with an Expect Respect facilitator about your feelings. The services you receive at school or in the community will not be affected if you choose to participate, choose not to participate, or choose to stop participating.

Potential Benefits

You will receive no direct benefit from your participation in this study. However, your participation may help CDC and SafePlace plan programs to keep young people safe and healthy. Your input will help these programs.

Subject's Rights

Your signature on this assent form means that you have received the information about this study and that you agree to volunteer for this research study.

You will be given a copy of this signed form to keep. You will also be given a letter about the study that you may wish to give to your parents.

You are not giving up any of your rights by signing this form. Even after you have signed this form, you may change your mind at any time. Please contact the study staff if you decide to stop taking part in this study. If you choose not to take part in the research or if you decide to stop taking part later, your rights and services will stay the same as before this study was discussed with you.

If you feel you have been harmed by the study or if you have any questions or concerns about this study, at SafePlace you can contact Dr. Barbara Ball (512-356-1623) or Ms. Barri Rosenbluth (512-356-1628). At CDC you can contact Dr. Andra Teten (770-488-3936). You may call them during the day or leave a message at these numbers after hours. You may also reach Dr. Andra Teten by mail at: CDC, 4770 Buford Highway NE, MS F-64, Atlanta, GA 30341.

Privacy:

You will be asked not to write your name on the survey. Everything that you write will be kept private as allowed by law. Only certain people working on this project will be allowed to look at the surveys. We will not use your name in any reports we write.

For your safety there are some things you may tell the facilitator that they cannot keep private. If the facilitator becomes aware that you or another young person has been abused they will have to tell someone. If the facilitator suspects that you are in serious danger of hurting yourself or someone else, they will have to tell someone. In these cases, the facilitator would contact people or agencies to keep you and others safe.

If the facilitator becomes aware of these events, they will discuss the situation with their supervisor. They will also discuss it with you, your school counselor and your parent or guardian. Everyone will work together to ensure your safety and the safety of others.

Only certain people who work on this study at SafePlace will be allowed to look at the surveys. No one else will know what you have written on the surveys and the surveys will not have your name on them.

An institutional review board (IRB) is a group ensures that studies are conducted in a safe way. The IRB for the Centers for Disease Control and Prevention has reviewed and approved this study.

I agree to take part in this project. I have read this form and I have been given a chance to ask questions. I understand that I will be given a survey to complete now/soon, and additional surveys in 8, 12 and 18 months. I understand that I can choose not to take part in the survey at any time.

______________________________________________________________________

Youth Signature

_______________________________________________________________________

Youth Name (Please Print)

_______________

Date

I give permission to be contacted for follow up surveys

• At school

• By Phone ______________________________

• By E-mail _______________________________

• By Mail ___________________________________

______________________________________________________________________

Youth Signature

_______________________________________________________________________

Youth Name (Please Print)

_______________

Date

Sample Expect Respect Support Groups Student Assent Verbal Script

Hi. My name is [name]. I work at SafePlace, an organization that helps people who have experienced family violence or sexual assault and works to prevent abuse and promote positive relationships in our community. I’m trying to learn how teens feel about their dating relationships and what we can to improve programs for teens that help them figure out positive relationships. Your school may or may not offer a dating violence prevention program. I would like to ask you to help me by being in a study to see how students in schools with or without these types of programs handle relationships and conflict. By being in this study, you will help me to understand if these programs are helpful to you and other students. I want to explain what will happen if you decide to help me.

I will ask you to complete three surveys about your relationships and your feelings and attitudes about those relationships. Each survey takes about 45 minutes to complete and will be administered now (or soon), once 8 months from now, a year from now (or at the beginning of next school year), and then again a year and a half from now. I will contact you when it is time to complete each survey. This is not a test, and there are no right or wrong answers.

Some of the questions in the survey are personal and might cause you to feel upset, nervous, or uncomfortable for a short time. If at any time you do not feel comfortable continuing the survey, you will be able to stop participating in the study. You will also have the opportunity to stop the survey at any time to discuss your experiences with me (or another counselor) in private. You do not have to take part in these surveys in order to receive any services at school or in your community.

What you talk about is private. That means that I will not repeat what you say to others including your teachers, counselors, other students or your parents. Some kinds of information cannot be kept private, though. If I become aware that you or another minor has been abused or assaulted, or if I suspect that you are in serious danger of hurting yourself or someone else, I will have to contact outside professionals or agencies, such as the Department of Protective and Regulatory Services, to help you and to keep you and others safe. If I become aware of these events, I will discuss the situation with my supervisor, you, your school counselor and your parent/guardian so that everyone can work together to ensure your safety and the safety of others. Neither I, your parents, teachers, counselors, or classmates will not know what you have written or reported in the surveys. The surveys will not have your name on them. Only certain people who work on this project at SafePlace will be allowed to look at the surveys.

You are not giving up any rights by signing the student assent form. If you don’t want to be in this study, you don’t have to be. I won’t be upset, and no one else will be upset, if you don’t want to be in the study. If you want to be in the study now but change your mind later, that’s okay, too. You can stop at any time. If there is anything you don't understand, you should tell me so I can explain it to you better. I will give you a copy of this form to keep, and you will also be given a letter about the study that you can give to your parents if you would like to.

You can ask me questions about the study. If you have a question later that you don’t think of now, you can call me or send me an email. You can also contact Barbara Ball or Barri Rosenbluth (see numbers on Student Assent Form) at any time if you need to report an injury related to this research. You may also contact Dr. Andra Teten at CDC about the study.

An Institutional Review Board, or IRB, is a group of people who ensure that research studies like this one are conducted safely. An IRB has reviewed and approved all of the information about how I am going to collect survey data from you, and how I will use those data in the future.

Do you have any questions for me now?

Would you like to be in my study and answer some questions in these surveys for me?

Expect Respect Parent Notification Letter

Dear Parent:

The ___________ School District is participating in an evaluation of Expect Respect, a program developed by SafePlace in Austin to help students choose safe and respectful relationships and prevent dating abuse. The Centers of Disease Control and Prevention are assisting SafePlace in evaluating the effectiveness of this program by inviting students to complete surveys about their relationships. Some schools in the study will provide the program and others will not. The results of this study will help us understand if Expect Respect is effective at increasing safe and respectful behaviors and decreasing violence and abuse.

You are receiving this letter because your child was invited and agreed to participate in the Expect Respect program evaluation. As part of this evaluation your child will complete 4 surveys (now, and in 8, 12 and 18 months from now). Your child’s name will not be attached to any survey. No student names will be used in the analysis or reporting of data at any time. Participation is voluntary and your child can stop participating at any time. If your child needs additional support the SafePlace/Expect Respect and school counselors will work together to meet your child’s needs.

If you would like more information about the Expect Respect program evaluation, please contact Dr. Barbara Ball, Program Evaluation Specialist, SafePlace at (512) 356-1623 or BBall@SafePlace.org.

Thank you very much for your support,