Attachment H_Assent and Parent Consent

Survey of NSCAW Adopted Youth, Young Adults, and Adoptive Parents

OMB #: 0970-0555

Expiration Date: 09/30/2021

Attachment H. Assent Form for Youth and Parent Consent Form for Youth

National Survey of Child and Adolescent Well-Being

	Survey of Family Well-Being
	RTI International  PO Box 12194  Research Triangle Park, North Carolina 27709l  USA Sponsored by: Administration for Children and Families Conducted by: RTI International

Assent for Youth to Participate in a Research Study (Child only Interviewed by Telephone)

Hello, my name is __________________. ______________ has given permission for you to talk with me today.

[Introduction]

We would like to invite you to join a research study. A research study is a way to find out new information about something. You can take part or not. Either way is fine. Please ask any questions before you decide.

[Purpose]

The government wants to learn about the needs of teenagers like yourself and to help improve programs and services for children. Many years ago, you or your parent joined a study called the National Survey of Child and Adolescent Well-Being. In this new study, the Survey of Family Well-Being, we are speaking with youth and their parents who joined that study. The government will use this information to make improvements and better support families.

[Types of Questions]

If you agree to join, we will ask questions about places you’ve lived, how you feel about your family, and about people who may help you. We also ask questions about things that may have happened in your life like living in foster care, being homeless, or running away. If you were adopted, we would like to know more about that.

If you agree to join this study, we would also like to link the answers you give now with the answers that we collected when you or your parent joined the study several years ago.

[Time Involved]

Our talk today will last around 30 minutes.

[Possible Risks or Discomforts]

We ask questions that might make you feel uneasy or sad. You do not have to answer questions you do not want to answer. If you want to stop, then all you have to do is tell me. If you want to take a break at any time, just tell me.

We cannot conduct this study unless it has been given a number from the government Office of Management and Budget. This information collection is number XXXX-XXXX and expires on XX/XX/XXXX.

[Privacy]

We do many things to make sure your answers stay private. I will not share your answers with your parent. We have a federal Certificate of Confidentiality for this study to protect participants’ identity. This certificate severely limits us from giving out any information that would identify you with anyone, even from a court order.

We may share your research data for future research without your name and any personal information. We will not ask for your additional informed consent for these studies.

We will not tell anyone your answers unless we are worried about you or someone else’s safety. For example, if you tell us you might hurt yourself or someone else, we may tell someone. If you tell us someone hurts you, we may tell authorities to keep people safe.

When we finish, we will send you a $30 gift card for taking part.

May I talk to you and ask you the questions?

[If participant has questions and requests talking with the project director or ethical committee representative say:

For study related questions, please call Heather Ringeisen, toll-free at 800-334-8571 extension 26931. For questions about your rights as a research participant, please contact the RTI Office of Research Protection at 1-866-214-2043.

	YOUTH AGREES
	YOUTH DOES NOT AGREE
	YOUTH DID NOT APPEAR TO UNDERSTAND EXPLANATION

National Survey of Child and Adolescent Well-Being

	Survey of Family Well-Being
	RTI International  PO Box 12194  Research Triangle Park, North Carolina 27709l  USA Sponsored by: Administration for Children and Families Conducted by: RTI International

Parent Permission for Child Participation (Child only Interviewed by Telephone)

The interview with your child will last around 30 minutes. We will ask questions about places your child had lived, how [CHILD] feels about your family, and about people who may help [CHILD]. We also ask questions about things that may have happened in [CHILD] ‘s life like living in foster care, being homeless, or running away. If [CHILD] knows that he/she was adopted, we would like to know more about his/her feelings and thoughts about adoption.

The voluntary participation, risks, benefits, and privacy of this survey are the same as those described to you on the consent form we reviewed before your interview.

I will ask for your help to talk with [CHILD]. At that point, <INSERT CHILD FIRST NAME> may choose whether to participate in the study. To protect your privacy and that of your child, neither of you will know the other’s answers to the interview questions. One exception to note: We will not tell anyone your child’s answers unless we are worried about your child’s safety. If your child tells us they might hurt themselves or someone else, we may tell someone. If they tell us someone hurts them, to keep them safe, we will inform the appropriate authorities.

We will give your child a $30 gift card for participating.

Do you have any questions?

[IF PARTICIPANT HAS QUESTIONS AND REQUESTS TALKING WITH THE PROJECT DIRECTOR OR ETHICAL COMMITTEE REPRESENTATIVE, SAY]

For study related questions, please call Heather Ringeisen, toll-free at 800-334-8571 extension 26931. For questions about your rights as a research participant, please contact the RTI Office of Research Protection at 1-866-214-2043.

[IF PARTICIPANT DOESN’T HAVE QUESTIONS]

Do we have your permission to approach your child for an interview?

	PARENT OF YOUTH AGREES
	PARENT OF YOUTH DOES NOT AGREE