Sample Assent Form

TITLE

Youth Assent Form

PERSON IN CHARGE OF RESEARCH:

John Doe, Ph.D.

Professor, School of Social Work

University of AlaskaAnchorage

907-786-XXXX

PURPOSE OF RESEARCH:

This research group is made up of four social work students from the University of Alaska Anchorage who are interested in learning about your experience with the Chafee Foster Care Independence Program.

Our purpose is to find out about your experiences in this program and how well it is working for you (if you are presently in State’s care) or how well it worked (if you are out of State’s care).

We plan to interview 10 youth or young adults who have participated in this program to hear about what they think of it. How you actually experienced this program will help us understand common experiences, common challenges, and common strengths. We would like to assist in making the program work better in the future.

WHO MIGHT PARTICIPATE?

Participants are youth or young adults ages 14-19 in Office of Children’s Services (OCS) custody and are presently in foster care or relative care and also young adults ages 18-22 in OCS custody at anytime after their 16th birthday.

WHAT DO I DO?

You will be asked six questions by an interviewer (one of the four social work students) and you will be free to answer each one as openly and honestly as you want about your experience with the Independence Program.

HOW WILL THE PROCESS GO?

  1. This research group will ask for your permission in writing to interview you.
  1. A member of the research group will contact you after you have given written permission to set up a day and time to interview you.
  1. At the interview, the student interviewing you will ask for your permission to record the interview on a tape recorder. This is only to keep track of everything you say and the tape will be destroyed after the interview is typed up.
  1. If at any time during the interview you do not wish to continue, then you are free to stop the interview with no questions asked. The interview will take no longer than one hour.
  1. Your interview along with the others will be used in a report about youth and young adult experiences in the Independence Program.

WHERE WILLTHIS HAPPEN?

The interview will take place at the University of Alaska Anchorage, LearningResourceCenter. Or, if you prefer, we can do it by phone.

WHY IS THIS RESEARCH HAPPENING?

We hope this research will help the Office of Children’s Services (OCS) to better understand young adults’ and youths’ viewpoint and ideas about the Independence Program so that OCS canserve youth in State care in the best possible way.

YOU ARE FREE TO CHOOSE:

Taking part in this interview is up to you. Not taking part or stopping at any time will not affect any services you might receive.

You do not have to talk about anything that might make you uneasy or uncomfortable. You will never be penalized for choosing not to participate.

WHAT YOU SAY WILL BE KEPT PRIVATE:

Your name or anything that might identify who you are will not be written down. We want to tape record the interview to make sure we do not miss anything important. Later, the tape of the meeting will be put into written form.

The tape will be destroyed after writing it down. Your quotes may be used in the final report, but nothing that could identify you will be used.

RISKS:

It is possible that talking about the Independence Program might make you uneasy. If you become upset at any point, you may stop talking until you feel better, or you can stop the interview. Everyone interviewed will be asked about the interview to insure that there are no negative feelings about participating. If it is determined that participants are in need of further counseling, they will be referred to the appropriate services. And we will make sure that needed services are provided.

BENEFITS:

By participating in this study, you will be able to describe your feelings and experiences about growing to adulthood with OCS. Your participation mayhave a positive influence for future OCS programs and for the youth who will face the same challenges.

COMPENSATION:

In appreciation for your participation, you will receive $10.00 after the interview.

PEOPLE YOU CAN CALL:

If you have any questions about the interview, you may contact:

Research Team:

Phil TafsTara Prewitt

234-XXXX229-XXXX

Or the Professor in Charge:

John Doe, Ph.D.

786-XXXX

If you have any questions about your rights as a research participant, contact Dr. Claudia Lampman, Compliance Officer, at (907) 786-1099.

SIGNING YOUR NAME:

Signing your name below means that you freely agree to take part in this study. You should agree only if you have read this paper or it has been read to you and you understand and agree to what it says.

Sign your name: ______Date ______

A copy of this form will be given to you to keep.

Interviewer’s Signature: ______Date ______

(If assent is given over the phone.)

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