11 Phone Version_Assent Form for Accompanied Adolescent

OMB Number (0915-0368)
Expiration date (03/31/2023)

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. 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. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX03/31/2023. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, 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 this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Assent Form for Accompanied
Adolescent (Ages 13 – 17) Study Participation
Health Center Patient Survey

About the Survey

The Health Center Patient Survey is a research study being conducted by RTI International. The survey is sponsored by the Health Resources and Services Administration (HRSA). The survey is about people who receive health care at places like your health center. The survey will try to find out what kinds of health problems people have and how well the health centers are meeting the needs of the people who use them. You are one of 9,000 people that RTI has chosen to participate.

Participation

Your parent/guardian said it is okay for me to invite you to talk with me about your health and the services that you receive at the health center. If it is okay with you, I would like to ask you some questions. Some of the questions may be personal, such as questions about drug or alcohol use and your feelings. There also may be questions about HIV/AIDS and thoughts about suicide. Most of the questions are about less sensitive things like health care received and whether or not you have certain health conditions like asthma or diabetes. Some people will get a shorter interview, while others will take a bit longer. The interview may last about 40 minutes.

Voluntary Participation

You may choose whether or not you would like to participate. If you choose not to participate it will not affect any services you may receive at the health center or from any other programs. If you do not want to answer some of the questions you are asked, that is okay. If you decide not to finish the questions, that is okay too.

Benefits

There are not any direct benefits to you. However, you will be helping us learn more about the health needs of people who use health centers like the one you visit.

Compensation for Participation

If you participate, you will be provided with $25 gift card, check or a gift of equal value to thank you for your time.

Risks of Study Participation

There are two potential risks involved in study participation that we are aware of. One risk is that the questions we ask might make you feel uncomfortable or upset. If you feel uncomfortable or upset you may ask the interviewer to take a break or skip any of the questions. The other risk is that someone might find out what you tell us during the interview. To avoid that, please find a private place in your home to complete the interview where no one can hear your answers. We will also create and use a number instead of your name to identify your interview. This will prevent anyone from finding out what your answers were.

Your Privacy

Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it. I am going to enter your answers into the computer. As mentioned, your answers will be linked to a number instead of your name so no one else will know you answered the questions. The staff involved in this research has signed an agreement stating they will protect the privacy of the information you provide. The information that you tell me will not be shared with anyone at the health center. Your parent/guardian will not see your answers, and we will not discuss any of your answers with them. We will not ask you about your legal or immigration status. The responses your parent/guardian provides during the interview will be locked during your interview. The same applies to your responses if your parent/guardian completes their questions after you.

Exceptions to Privacy Pledge

There is an important exception. If I learn through the course of the interview that your life or health, or another person’s life or health could be in danger, I may be required to inform the clinic staff or the proper authorities.

Questions

If you have any questions about this study, you may call Azot Derecho, Data Collection Task Leader, at 1 (800) 334-8571 Ext 27231. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at 1 (866) 214-2043.

Recordings

We are using a special quality control system on this project. The system runs on the computer and will record what we say to each other during several different parts of the interview. Neither of us will know when the computer is recording what we say. The recording will be reviewed by people at RTI to monitor my work, and will be kept private. You may participate in the interview even if you do not consent to the recordings. May we use this quality control system during your interview?