OMB Number: 0970-XXXX [Insert logo here]
Expiration Date: XX/XX/XXXX
Hello:
The Administration for Children and Families (ACF) is part of the U.S. Department of Health and Human Services. ACF is funding a team at Mathematica Policy Research to learn more about how to teach youth about preventing pregnancy and promote sexual health through [interviews/online discussions]. [ORGANIZATION NAME] is taking part in it.
The purpose of the [interviews/online discussion] is to learn more about how youth make decisions related to sexual health, youth experiences with sexual health education, and how these programs could be improved to prevent unintended pregnancy and improve sexual health. We are asking you to participate in the [online discussion /interview]. During the [online discussion /interview], you will be asked about your experiences with sexual health education programs, how you think sexual health education programs could work better for youth like you, how you make decisions about relationships and sex, and how you get information about sexual health. Your point of view is extremely valuable to efforts encouraging the sexual health of youth. The [online discussion/interview] will take no more than ninety minutes to complete.
If you choose to participate, the information you share will be combined with information from other youth to describe their experiences with and attitudes toward sexual health education. Your name will not be attached to the answers you give, and no one outside the [online discussion and] study team will see your answers. The study team will keep all information collected private to the extent possible by law. [Additionally, the team will ask all participants to keep the information discussed in the online discussion private; however, there is a chance other participating youth may reveal information discussed in the online discussion to people who were not in the online discussion.]
Being part of this [online discussion/interview] is completely voluntary. There are no penalties or consequences for not answering our questions. We will ask some questions that deal with sensitive topics, like how you make decisions about relationships and sex. You do not have to answer any questions that you are not comfortable answering. You may also stop participating in the [online discussion/interview] at any point. There are no right or wrong answers to our questions.
If you agree to participate in the [online discussion/interview], you can choose to stop participation at any time with no consequences. You will receive a $20.00 gift card for [participating in the interview/joining the online discussion each day for 3 days]. There are no additional benefits to you for participating in the [online discussion /interview].
Please let us know whether you will participate in the [online discussion/interview] by completing and signing the attached form. Return it to [CONTACT PERSON].
Please call Mathematica toll-free at X-XXX-XXX-XXXX if you have questions about the study.
Sincerely,
Jean Knab, Ph.D.
Project Director
Mathematica Policy Research
Youth 18 or Older Consent Form for [Online Discussions/Interviews]
Sponsored by the United States Department of Health and Human Services
I have read the attached information sheet describing the [online discussions/interview]. By signing this form, I am:
□agreeing □not agreeing
to participate in the [online discussions/interview].
If agreeing to participate, I understand I will be asked about my experiences with sexual health education, how these programs could be improved, and decision making about relationships and sex. I agree to this information being collected. Additionally, I understand that participation is voluntary and may be withdrawn at any time for any reason without penalty. I further understand all information will be kept private by the study team and used only for the purposes of the study. [I also understand the study team will instruct participants to keep the information private, however there is a chance other participants may reveal information discussed in the online discussion to people who were not in the online discussion.] If I have questions about my rights as a research volunteer, I can call the New England Institutional Review Board, toll-free at 1-800-232-9570.
Signature: ____________________________ ____ Date: _______________
Print Name: ___________________________________________
Date of Birth: _____ / ______ / _____
Month Day Year
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.
Page
NEIRB Version XX.0
| File Type | application/msword |
| File Title | PAF Consent Letters and Forms and Youth Assent Form |
| Subject | Forms |
| Author | Sara Forrestal |
| Last Modified By | SYSTEM |
| File Modified | 2017-08-03 |
| File Created | 2017-08-03 |