Form 5 Attachment J One-toOne Evaluation Study Child Assent For

OMB Control Number: 0925-XXXX Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 5 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

innovation Research & Training, Inc.

Address: 1415 W. NC Highway 54, Suite 121, Durham NC 27707

Voice: 919 493-7700 Fax: 919 493-7720

Dear Youth,

We are asking you to try out a new educational website for young people your age and tell us what you think about it.

Please read this letter which contains information to help you decide if you want to help us. Please ask as many questions as you want to be sure you understand what will happen and what you will do. One of the project staff members will be happy to answer them.

What is the purpose of this project?

We want to get your help on some ideas for a new website. We want to know what you think about some activities we’ve created. We want to know if you find the website fun, interesting, and helpful to you. We also want to know if you find it easy to use the program. Once we get your help, we can then decide if we need to make any changes to our website.

What will I have to do?

You will be asked to:

1. Review our new website.

2. Answer a few questions on whether the website was easy to use and follow along with and if you liked the content in the website.

3. Answer a few questions about yourself, for example, your age.

The interview may take you up to 2 hours and you will get to take a break when needed. Your parent/caregiver has given permission for you to help us by being in the study, but you still can decide for yourself if you want to do it or not.

Will my answers be kept private?

Yes, all of your answers will be kept private. Your name will not be on anything we keep for this project.

What happens if I don't participate in the project?

You do not have to be in this project unless you want to. If you decide to be in the project, you do not have to answer any of the questions or participate in any of the activities that you don’t want to. You can choose to quit this project at any time.

Are there any risks to being in the project?

We do not think there are any real risks to you. If you don’t want to, you don’t have to participate in the study.

Will anything good happen as result of being in this project?

You will help us to make a website that can help a lot of youth, like yourself.

Will I get anything for being in the project?

For participating in this project, you will receive $25.

Who should I contact if I have any questions about the project?

The project is being done by Dr. Alison Parker and Dr. Tracy Scull of innovation, Research, & Training. If at any point during your participation in this project, you have any additional questions or concerns, you or your parent can contact Dr. Parker, at (919) 493-7700, email: aparker@irtinc.us or Tracy Scull, at (919) 493-7700, email: tscull@irtinc.us.

If you have any questions or concerns about your rights as a research participant or how you were treated, you or your parent should contact Barbara Goldman, Ph.D., Chair of the iRT Institutional Review Board (IRB), which reviews studies like this one, at barbara_goldman@unc.edu or 919-966-7169.

Thank you for your help!

Sincerely,

Alison Parker, Ph.D. Tracy Scull, Ph.D.

Co-Principal Investigator Co-Principal Investigator

innovation Research &Training innovation Research & Training

One-to-One Evaluation Study

YOUTH AGREEMENT

In this study, you will be asked to:

• Review a new website

• Provide feedback on what you see in the website

You do not have to be in the study if you don’t want to, and you can stop being in the study at any time. You do not have to answer any questions that you don’t want to answer. Your answers will be kept private.

Yes, I would like to be a part of the One-to-One Evaluation Study.

Child’s Name (please print) Date

Your Caregiver’s Name (please print) Date

Please keep one copy of this 4-page form and turn in the other one with your name on it.

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