Updated August 2014
University of Chicago
School of Social Service Administration
Parental Consent to Participate in Research
STUDY NAME
Ø What is this study?
You are being asked to take part in a research study being conducted by [XXX, and XXX] from the University of Chicago. Based on our phone conversation you expressed as interest in participating in this research study. The purpose of the study is to evaluate the effects of the neighborhood summer program called [XXX] funded by the Bureau of Justice Assistance.
As you may know, the summer program aims to provide activities including employment training for youth during out-of-school time. Because we want to be able to evaluate the effects of the summer program, we are asking youth and their parents who are participating in this summer program to speak with us regarding the summer program activities.
Approximately 500 people will be interviewed for this research study including 200 parents at community organizations or other public venues and 300 youth.
Ø What will you and your child be asked to do?
You and your child are being asked to agree to a one time, 45 minute to one-hour interview that will be completed now or at another time convenient for you or your child in the next two weeks. Individual interviews will take place at the community center, at a café, public library or at offices at the University of Chicago.
The purpose of the interviews is to understand you and your child’s perspective and experiences in this summer program. Each interview will be audio-recorded if it is okay with you and your child.
Ø What kinds of questions will I ask you and your child in the interview?
We will ask you questions about your perspective on the summer program, your understanding of the types of community-level support offered by the program, the number of people in your neighborhood who you know are participating, and your family structure.
We will ask your child questions about their interests and skill needs, their career development from the program, their health and fitness activities, and their level of social competence and perspective on peer relations.
Ø Do you have to answer all my questions?
No, you do not have to answer any questions or participate in this interview. Your decision to participate or answer questions is completely up to you. Participation in the study interview is voluntary. You or your child may end participation in the interview at any time, or chose not answer a question or discuss a topic. You do not have to give a reason for not answering a question.
Ø Will the information you give be confidential?
Yes, the information you and your child provide in the interview will be shared only with the University of Chicago research team. All of the information that you give us will be kept private. Nothing that you tell us will be shared with summer program staff, summer employers or anyone else.
When the results of this research study are published or discussed, no information will be included
that will reveal your identity. Your identifying information and your child’s identifying information
will be destroyed at the end of this study. Data that does not contain personal information will be kept
for xxx years.
Ø Exceptions to confidentiality
As university employees we are required by law to report child or elder abuse to the Department of Children and Family Services and foreseeable harm to others or self to law enforcement.
These three exceptions to confidentiality are:
1. Where there is a reasonable suspicion of child abuse or elder adult physical abuse;
2. Where there is a reasonable suspicion that you may present a danger of violence to others; or
3. Where there is a reasonable suspicion that you are likely to harm yourself unless protective measures are taken.
Ø What risks are there if you participate in this study?
There are minimal risks to participation in this study. The most likely risk is that some of the questions may make you feel uncomfortable. Again, you may choose not to answer some questions if you are uncomfortable. You may end your participation in the interview at any time, or chose not answer a question or discuss a topic. You do not have to participate in this interview and can withdraw permission for participation in this project at any time.
The information you and your child provide, audio recordings and notes, will remain strictly confidential, unless there is evidence that you or if a child is in danger of hurting himself/herself or others. In this rare case, we are required to report such information.
Ø Voluntary participation and withdrawal
Your decision whether or not to participate will not affect your current or future relations with the summer program or with the University of Chicago. Likewise, if your child’s decision where or not to participate will not affect his/her current or future relastions with the summer program. Your participation is completely voluntary. You and your child can choose whether to be in the study or not.
If you volunteer to be in this study, you may withdrawal at any time without consequences of any kind. If you decide to participate, you can skip any question for any reason. You can also stop participating at any time. Your child may do the same.
Ø What benefits are there if you participate in this study?
There are no direct benefits to you, but it is an opportunity to influence the types of summer services that will help youth during summer months. Many people enjoy and appreciate the chance to know that their opinions are listened to and used in improving their neighborhoods and youth services.
Ø Will you receive any payment if you participate in the study?
Yes. To compensate you for your time, you will be given a $10 cash payment at the end of the interview. If your child agrees to participate, he/she will also be given a $10 cash payment for their time. You or your child will receive this payment even if you or your child do not answer all of the questions we ask you.
Ø Who should I contact if I have questions?
If you have any questions about this evaluation study or the interviews, please contact the University of Chicago researchers conducting the study.
XXXXXX
University of Chicago
School of Social Services Administration
xxxxx Street
Chicago, IL 60637
(xxx) xxx-xxxx
If you agree to participate in this study and feel that your rights have been violated, or you were not treated fairly please feel free to contact:
Institutional Review Board (IRB) Director
University of Chicago
SSA/Chapin Hall IRB
969 East 60th Street
Chicago, IL 60637
(773) 834-0402
Ø Please review and check the boxes below to indicate that each of these conditions and your questions have been answered to your satisfaction.
¨ You understand that you will be one of 500 parents and their children participating in this study.
¨ You understand that you and your child are being asked to agree to a one time, 45 minute to one hour interview that will be completed now or at another time convenient for you or your child in the next two weeks.
¨ You understand that your participation and your child’s is voluntary and refusing to participate or to answer any questions will not jeopardize any benefits or services you or your child have or might receive.
¨ You understand that everything you and your child say in the interviews will be kept confidential to the extent allowed by law as described above, and will not be shared with anyone outside the university research team.
¨ You understand that your identifying information and your child’s information will be destroyed at the end of this study.
¨ You understand that de-identified data collected for the study will be destroyed in xxx years.
¨ You understand that you or your child do not have to answer any questions you do not want to
without consequences.
¨ You understand that this study gives you an opportunity to express your opinion on how parents
and children can benefit from summer programs such as the [xxxxx name].
¨ You understand that you and your child will receive $10 each at the end of the interview.
children can benefit from summer programs such as the [xxxxx name].
¨ You will be given a copy of this study.
Agreement to Participate
I, ______[print name], understand the procedures described above. My
questions have been answered to my satisfaction, and I agree to participate in this study.
______
Signature of Participant Date Signature of Interviewer Date
I agree to allow my child, ______to participate in an interview for this research
evaluation.
______
Signature of Participant Date Signature of Interviewer Date