Youth Student Consent

Attachment 7. Focus Group Youth Consent Form (CBO)

DCPS Student Focus Group Discussion

Youth Consent Form

Purpose of Focus Group

The Centers for Disease Control and Prevention’s Division of Adolescent School Health is working with District of Columbia Public Schools (DCPS) and [insert CBO name] to hold a focus group with students to learn more about school-based sexual health services including access and use of the school-base heath center, sexually transmitted disease testing, and condom availability. We would like to get students’ general opinions about what makes it easy or hard to access school-based health centers and sexual health services at school. We will NOT be asking about your own behavior or personal use of services. Information from the focus groups can help DCPS improve student access to services in the future.

ICF, a private company, was hired to conduct the focus group. Youth who self-identify as LGBTQ who affiliate with [insert CBO name] and are currently enrolled in 9^th-12 grade at select DCPS high schools have been invited to be in a focus group. Of those, 12 youth will be selected to be in the focus group. The focus group will last about 90 minutes and will be conducted at [insert CBO name] outside of school hours. Youth will be asked questions regarding your thoughts and views of student access to sexual health services, use of school-based health centers and other sexual health services. Please note: We are not providing transportation, so if you are willing to participate, you will need to arrange transportation. Should you be selected to participate, advanced notice will be given with the day and time of the focus group to help with planning.

Possible Risks to Students

Being in the focus group is expected to cause no harm to you. However, some questions may make you uncomfortable. You may choose to not answer any question or to stop participating at any time.

Privacy

If selected for the focus group, we will protect your privacy. Your name will not be on any focus group notes or reports. Focus groups will be audio-recorded to help keep track of what is discussed, but names will not be used and all records (such as this consent form) will be kept private. Your participation is completely voluntary. You can stop at any time or skip any question that you do not want to answer.

It is Voluntary

Being in the focus group is up to you. You may choose not to participate. This will not affect use of services at [insert CBO name] and no one will hold it against you. Even if you agree to participate, you may decide not to take part in the focus group or to stop at any time. If you participate in the focus group, you will receive a gift valued at $30 as a thank you. If you decide to leave the focus group before it is over, you will still be given the gift.

Potential Risks and Benefits to Taking Part

There are minimal risks to being in the focus group. If you take part in the focus group, your feedback could help DCPS find ways to improve student access to sexual health services. This has the potential to impact the overall health and well-being of students.

However, if you decide to share voluntary information that is subject to mandatory reporting laws, project staff will work with you to make the report to authorities. Although none of our questions will ask you specifically about these topics, there are some times when we cannot promise to keep information private. For example, if you tell the moderator that you plan to hurt yourself or someone else, the moderator will have to tell someone that can help. Also, if you are under 18 years old and talk about having sex with someone over 18, this would have to be reported. Moderators also have to obey laws about reporting child abuse and neglect to authorities. Child abuse means someone hurting a child’s body, forcing a child to do something that hurts them, or leaving a child with no place to live, or no food or things he or she needs to be safe and healthy.

Questions

If you have any questions about the focus group or your rights as a participant, you may call the ICF Institutional Review Board by phone at 877-556-2218 or Thearis Osuji, ICF Project Manager, at 404-321-3211.

Please read below and check “YES” or “NO” if you agree to take part in the focus group. Then, sign, remove this page, and return it to the school within 7 days. The first page is yours to keep.

I have read this form and know what the focus group is about.

[ ] YES, I agree to take part in the focus group. If selected, I understand that I must provide transportation from [insert CBO name] on this day.

[ ] NO, I do agree to take part in the focus group.

Name (Print):

Signature:		Date:

School Where You are Currently Enrolled (Print)

Age:

Grade in School

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