Appendix C: Assent form for youth with IDD participants

OMB #: 0970-0531 [Insert logo here]

Expiration Date: XX/XX/XXXX

STATEMENT OF STUDY ASSENT FOR VOLUNTARY PARTICIPATION

Youth 13-17 Years Old

Sponsored by the U.S. Department of Health and Human Services

An adult from Mathematica has explained the study to me. I understand that I am taking part in a focus group. A focus group is a discussion that Mathematica will lead with the youth in my class. If for some reason they cannot do a focus group at my school, I will be asked to do a short interview. The interview questions will be the same as the focus group questions.

The study team wants to learn about my thoughts on the Internet safety lessons my teacher gave us from the Digital Citizenship curriculum. During the focus group, I will be able to share my thoughts about the lessons and how much I like them. I can also share ideas about how the lessons could be better. The study team will not ask you my own behavior.

The study team person described the study to me and answered my questions. The person told me that my parent or guardian has agreed to let me take part in the discussion.

I understand I will not get any direct benefits for being in this discussion, but I will learn about Internet safety and help make the lessons better for other youth.

Mathematica will keep everything you tell us private. That means no one outside of the study team will see your answers, like your teachers, parents, or guardians. I understand the study team has asked all youth in the focus group to keep the information discussed private. I also know there is a chance that someone might share what is said with people outside the group. I understand the only risk to me during this discussion is that I might not be comfortable answering some questions. If that happens, I do not have to answer the questions. I can also stop taking part in the discussion at any time and will not get in trouble.

If I have questions about my rights as a research volunteer or questions about the study, I can call:

• The HML IRB, toll-free, at 1-202-246-8504, or

• Katie Adamek at Mathematica, at 1-617-583-1940.

I understand that it is my choice to take part in the discussion and that I can stop at any time. I understand the study team will audio-record this discussion if everyone agrees and that I can still take part, even if I do not agree to be recorded.

Please mark your responses below:

1. I agree to take part in the [interview/discussion]

Yes No

2. I agree to be recorded during the focus group or interview.

Yes No

____________________________ ____________________________ _______________

Name Signature Date

------------------------------------------------------------------------------------------------------------------------------------------

I certify that the staff members assigned to explain the study to participants were trained to do so in terms participants would understand.

Jean Knab

Project Director, Mathematica

[Signature Date]

Approved by [IRB] on XX-XX-XXXX

[IRB] Version 1.0