Attachment E Youth Focus Group Assent

ATTACHMENT E

 YOUTH FOCUS GROUP ASSENT FORM  

Form approved

OMB Number: 0990-0480 

Expiration Date: 10/31/2024

Focus Groups – YOUTH ASSENT FORM

REAL Essentials Advance study

Sponsored by the United States Department of Health and Human Services

Earlier this year, your parent/guardian agreed to that you can participate in the REAL Essentials Advance (REA) study. The REA Study is sponsored by the Office of Population Affairs (OPA) in the U.S. Department of Health and Human Services (HHS). As part of the REA study, members of the study team will be conducting a [virtual] focus group discussion with youth about their experiences with the REA curriculum.

You are being invited to participate in the focus group discussion and your parents/guardians have given their permission for you to participate in the focus group.

• During the focus group, you will be asked to discuss your experiences and satisfaction with REA. You will not be asked to share your own personal behaviors with the group.

• The discussion will take no more than an hour and a half and you will receive [incentive] for participating in the discussion.

• With each participant’s permission, the discussion will be recorded. You can still participate in the focus group, even if you do not agree to be recorded.

• Your name will not be attached to any of your responses and you do not have to answer any questions you do not want to answer. The information you provide will be kept private to the extent permitted by law and will not be shared with anyone outside the study team. However, if you report that you are going to hurt yourself or that someone is hurting you, the study team will take steps to report this to someone who can help make sure you are safe.

• Participants in the focus group will be asked to keep all comments made during the focus group discussion private and not to talk about them with anyone outside of the discussion group.

• The only risk to participation is that you may feel uncomfortable answering some of the questions. There are no direct benefits to participating. Your participation in the focus group is voluntary, and you can stop participating in the focus group discussion at any time, without penalty. If you have questions about the study please call Melissa Thomas, Survey Director at Mathematica, toll-free at 1-800-XXX-XXXX.

• If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board (HML) toll-free at (202)246-8504.

Please mark your responses below and sign the form if you agree to participate in the discussion.

1. I agree to participate in the focus group discussion, as part of the REA study.

Yes No

2. I agree to be recorded during the discussion.

Yes No

3. I agree not to discuss any comments made during the discussion with anyone outside of the focus group.

Yes No

Name		Signature		Date