Att 10_Example Active Parental Consent Form

Attachment 10

Example Active Parental Consent Form

Student Focus Group Discussion

Parent Consent Form

Purpose of Focus Group

The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent School Health (DASH) is working with Fort Worth Independent School District (FWISD) to hold focus groups with students to learn more about their health education curriculum, specifically the lessons on HIV, sexually transmitted disease (STD), pregnancy prevention, and abstinence. We would like to get students’ opinions about what they are learning and how the material is being presented. Information from the focus groups can help FWISD improve health education in the future.

ICF International (ICF), a private company that was hired by CDC, will conduct focus groups. All students currently taking health at your child’s high school will be invited to participate. Of those, 48 students from 2 high schools will be selected to be in a focus group. The focus group will not interfere with your child’s instructional time. The focus groups will last about 90 minutes and will be held outside of school hours. Focus groups will be separated according to gender; male students will be in a separate group from female students. Students will be asked a variety of questions regarding class content on abstinence, pregnancy prevention and STD prevention and how the material was taught. Please note: We are not providing transportation for this study, so if you are willing to let your child participate you and/or your child will need to arrange transportation for your child to attend the focus group. Should your child be selected to participate, advanced notice will be provided with the day and time of the focus group to help with planning.

Possible Risks to Students

Participating in the focus group is expected to cause no harm to your child. However, some questions may make your child uncomfortable. Your child may choose to not answer any question or to stop participating at any time. If you would like to see a copy of the focus group questions, you can call or email XXX at Fort Worth Independent School District: XXX or email XXX.

Privacy and Confidentiality

If your child is selected for the focus group, we will protect your child’s privacy. Your child’s 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 participant records (such as this consent form) will be kept confidential. Your child’s participation is completely voluntary. He or she can stop at any time or skip any question that he or she does not want to answer.

It is Voluntary

Participating in the focus group is up to you and your child. You may choose for your child to not take part. This will not affect class grades and no one will hold it against you or your child. Even if you allow your child to participate, your child may decide for him or herself to not take part in the focus group or to stop at any time. If your child participates in the focus group, he or she will receive a $30 Target gift card as a thank you. If your child decides to leave the focus group, he or she will still be given the card.

Also, there will be a prize drawing for ten $20 Target gift cards that will be given away at your child’s school for those students who return a signed consent form. Even if you do not give permission for your child to take the survey, he or she can still be entered into the drawing. If you want your child to take part in the drawing, (1) sign the consent form, (2) mark whether you do or do not allow your child to participate, (3) check the box at the end of this form to indicate your interest in the drawing, and (4) provide your address and phone number so we can notify you if your child’s name is chosen.

Potential Risks and Benefits to Taking Part

There are minimal risks to taking part in the focus group. However, if your child decides to share voluntary information that is subject to mandatory reporting laws, project staff will work with the school staff and the youth to make the report to authorities. There are some times when we cannot promise to keep information private. Although none of our questions will ask students specifically about these topics, if your child tells the interviewer that he or she plans to hurt him/herself or someone else, the interviewer will have to tell someone that can help, like the police. Interviewers also have to obey laws about reporting child abuse and neglect to the authorities. Child abuse means someone hurting your child’s body, forcing your child to do something that hurts him or her, or leaving your child with no place to live, or no food or things he or she needs to be safe and healthy. If your child talks about having any kind of sex with someone older than 18, the interviewer might also have to report this. If your child is selected to take part, he or she may benefit from taking part in the focus group. His or her opinions could help FWISD find ways to improve the health education curriculum which has the potential to impact the overall health and well-being of students.

Questions

If you have any questions about the focus group or your child’s rights, you may call the ICF Institutional Review Board by phone at 877-556-2218 or Colleen Murray, ICF Project Manager, at 404-321-3211.

Please read below and check “YES” or “NO” if you do or do not allow your child to take part in the focus group. Then, sign, detach 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 allow my child to take part in the focus group, and if selected I understand that I must provide transportation from school on this day.

[ ] NO, I do NOT allow my child to take part in the focus group.

Parent’s Name (Print):

Parent’s Signature:		Date:

Student’s Name (Print):

Student’s Age:

Student’s Grade:

If you are interested in being a part of the drawing…

Please check this box AND provide contact information below if you would like your child entered in the drawing to win a $20 Target gift card. It does not matter if you say “yes” or “no” to your child participating in the focus group – they will be entered in the drawing just for returning the form. Please give us a way to contact you or your child if their name is picked in the drawing.

Mailing Address:		Best Phone Number:
Email Address:		Alternate Phone Number:

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Author	Rose, India
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File Created	2021-01-20