ChalleNGe Cadet Survey

Office of the Assistant Secretary of Defense (Reserve Affairs)

A30500

20121088

Research subject information and Consent form
TITLE:	The Impact of ChalleNGe on Participants’ Noncognitive Skills

This consent form contains important information to help you decide whether to participate / have your child participate in a research study.

The study staff will explain this study to you. Ask questions about anything that is not clear at any time. You may take home an unsigned copy of this consent form to think about and discuss with family or friends.

• Being in / having your child in a study is voluntary – your choice.

• If you join / your child joins this study, you can still stop your / his or her participation at any time.

• No one can promise that a study will help you / your child.

• Do not join / have your child join this study unless all of your questions and your child’s questions are answered.

After reading and discussing the information in this consent form you should know:

• Why this research study is being done;

• What will happen during the study;

• Any possible benefits to you / your child;

• The possible risks to you / your child;

• Other options you could choose instead of being in / having your child in this study;

• How your / your child’s personal health information will be treated during the study and after the study is over;

• Whether being in / having your child in this study could involve any cost to you; and

• What to do if you or your child has problems or questions about this study.

Please read this consent form carefully.

INFORMATION ON THE STUDY AND YOUR PARTICIPATION

Title: The Impact of ChalleNGe on Participants’ Noncognitive Skills (Protocol No. A30500; WIRB Protocol #20121088)

Sponsor/Source

of Funding: Office of the Assistant Secretary of Defense (Reserve Affairs)

Investigator: Lauren Malone, Ph.D.

3003 Washington Boulevard

Arlington, VA 22201

(703) 824-2741

STUDY

COORDINATOR(S): Ms. Jennifer Atkin

(703) 407-1048

This consent form may contain words that you do not understand. Please contact the study staff for an explanation of any words or information that you do not clearly understand. You are being provided this consent form in advance of your arrival at ChalleNGe so that you may think about or discuss it with family or friends before making your decision.

A person who takes part in a research study is called a research or study subject. In this consent form “you” always refers to the research subject, which is the cadet who will be enrolled at ChalleNGe.

SUMMARY

You are being asked to be in a research study. The purpose of this consent form is to help you decide if you want to be in the research study. Please read this form carefully. To be in a research study you must give your informed consent. “Informed consent” includes:

• Reading this consent form,

• Understanding the research study,

• Asking questions about anything that is not clear, and

• Taking the time think about whether or not you want to participate and to talk to family or friends before you make your decision.

You should not join this research study until all of your questions are answered. If you take part in this research study, you will be given a copy of this signed and dated consent form.

PURPOSE OF THE STUDY

The purpose of this study is to look at the impact the ChalleNGe program has on cadets’ noncognitive skills. Noncognitive skills are skills that are not academic like math and reading. They are skills like motivation and someone’s ability to stick with something. About 1,200 cadets will participate in this study at 7 ChalleNGe sites that have been selected for this study.

PROCEDURES

If you participate in the study you will complete a short survey when you arrive at ChalleNGe. In addition, if you graduate from the program, you will complete the same survey right before graduation. Each time you take the survey it will take approximately 10 minutes.

The survey asks about your attitudes and beliefs about different subjects. There are no right or wrong answers. You will be asked to choose the response that best fits you. You will take the survey on the ChalleNGe campus during normal program hours. You will not miss any classes while completing the survey.

BENEFITS AND RISKS AND DISCOMFORTS

You will receive no direct benefit if you participate in this study. But, your participation may help the National Guard Youth ChalleNGe program determine what changes should be made to the program to improve it. This could help increase the number of cadets who pass the General Educational Development (GED) and/or find good jobs. There are no risks to you if you participate in the study. The survey will ask you about your feelings and beliefs on several topics. If you feel any stress or discomfort while answering a question, you are free to skip it. You can even stop participating in the study altogether. If you choose not to participate or to stop participating, it will not impact your status as a ChalleNGe cadet or your ability to continue in the program.

COSTS AND PAYMENT FOR PARTICIPATION

There will be no cost to you for being in this study and you will not be paid for being in the study.

CONFIDENTIALITY

Information collected about you by the survey will be given to the sponsor. “Sponsor” means any persons or companies that are working for or with the sponsor, or owned by the sponsor.

The consent form signed by you will be looked at and/or copied for research or regulatory purposes by the sponsor and may be looked at and/or copied for research or regulatory purposes by the Department of Health and Human Services (DHHS) agencies and the Western Institutional Review Board^® (WIRB^®).

Total confidentiality cannot be guaranteed because of the need to give information to these parties. The results of this research study may be presented at meetings or in publications. Your identity will not be given out during those presentations.

PRIVACY ADVISORY AND VOLUNTARY PARTICIPATION AND WITHDRAWAL

This survey does not collect or use any personally identifiable information. Your participation in this survey will not be used to create individual profiles or given to any private organization. All survey responses are anonymous and will be securely transferred for analysis to the researchers associated with this project. Upon completion of this project, all data will be purged in accordance with Department of Defense data destruction procedures.

Your participation in this study is voluntary. You may decide not to participate or you may leave the study at any time. Your decision will not result in any penalty or loss of benefits to which you are entitled. You may skip any question that you do not want to answer, although maximum participation is encouraged so that the data will be complete and representative. Your participation in this study may be stopped at any time by the Principal Investigator or the sponsor without your consent for any reason.

AGENCY DISCLOSURE STATEMENT

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-TBD). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

QUESTIONS

Contact Dr. Lauren Malone, Principal Investigator, at (703) 824-2741 for any of the following reasons:

 if you have any questions about this study or your part in it, or

 if you have questions, concerns or complaints about the research

If you have questions about your rights as a research subject or if you have questions, concerns or complaints about the research, you may contact:

Western Institutional Review Board^® (WIRB^®)

3535 Seventh Avenue, SW

Olympia, Washington 98502

Telephone: 1-800-562-4789 or 360-252-2500

E-mail: Help@wirb.com

WIRB is a group of people who independently review research. WIRB will not be able to answer some study-specific questions. However, you may contact WIRB if the research staff cannot be reached or if you wish to talk to someone other than the research staff.

Do not sign this consent form unless you have had a chance to ask questions and have gotten satisfactory answers. If you agree to be in this study, you will receive a signed and dated copy of this consent form for your records.

CONSENT FORM

I have read this consent form. All my questions about the study and my (my child’s) part in it have been answered. I freely consent to be (allow my child to be) in this research study. By signing this consent form, I have not given up any of my (my child’s) legal rights. I authorize the release of my (my child’s) research records for research or regulatory purposes to the sponsor, DHHS agencies and WIRB^®.

Consent and Assent Instructions

1. Print the full name of the ChalleNGe cadet on the “Subject Name” line (A).

Consent Section:

2. In the case of cadets who are 18 years or older, the cadet (the “subject”) should sign and date the line “Signature of Subject”(B). No other signatures are required.

3. In the case of cadets who are under the age of 18, a parent or legal guardian should sign and date the line “Signature of Parent or Guardian” (C). The parent or guardian should also write their relationship to the cadet on the line “Relationship to Subject”(D).

Assent Section:

4. In the case of cadets who are under the age of 18, the cadet should read the “Information Sheet for Adolescents” and sign and date the line “Signature of Minor Subject” (F). A parent or legal guardian should also sign and date the line “Signature of Parent or Guardian”(E).

A. Subject Name (printed)

CONSENT SECTION:

B. Signature of Subject (for cadets 18 years or older) Date

C. Signature of Parent or Guardian (for cadets under age 18) Date

D. Relationship to Subject

ASSENT SECTION for Subjects Under the Age of 18:

Statement of person conducting assent discussion:

1. I have explained all aspects of the research to the subject to the best of his or her ability to understand.

2. I have answered all the questions of the subject relating to this research.

3. The subject agrees to be in the research.

4. I believe the subject’s decision to enroll is voluntary.

5. The study staff agrees to respect the subject’s physical or emotional dissent at any time during this research when that dissent pertains to anything being done solely for the purpose of this research.

Signature of Person Conducting Assent Discussion Date

Statement of Parent or Guardian:

My child appears to understand the research to the best of his or her ability and has agreed to participate.

E. Signature of Parent or Guardian Date

Statement of Minor Subject:

I agree to participate in this study.

F. Signature of Minor Subject Date

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