ࡱ> FHEe bjbj 4(xj\xj\)  8$9"""""8999999$);=$9$9""99F""8857"W^V68O909n6>>07>7h$9$9m9> > \: Assent to Participate in a Research Study (14-17 year olds) Title of Study Principal Investigator: Researcher X, Ph.D., Department of ----------, ݮƵ Co-Investigator: Researcher Y, Ph.D., Department of ----------, ݮƵ Overview and purpose Study description. We are asking you to be part of a research study that plans to --------------------------------. We contacted your family because ----------------. We plan to ask ---- children between the ages of -- and 17 to participate in our research. This study is funded by ----------------. Description of your involvement If you agree to be part of this study and at least one of your parents gives permission, you will talk to an interviewer about how this experience affected you. The interviewer will come to your home/school/other location to talk with you at a time that is convenient for you. The interview will take about ----- minutes. We would like to audiotape the interview to make sure that our conversation is recorded accurately, but you can still be part of the study if you dont want to be audiotaped. Voluntary nature of the study Participating in this study is completely voluntary. Even if your parents say you can talk to us, you do not have to do so. Even if you say yes, you may change your mind and stop at any time. You may also choose to not answer a question for any reason. Benefits While you may not receive a direct benefit from participating, others may benefit from the knowledge obtained in this study." Risks and discomforts Answering questions about ---------------- may be uncomfortable. You can choose not to answer a question or you may stop the interview at any time. Just tell the interviewer you want to stop. Compensation You will be paid $--- for participating in the full interview. If you decide to quit before the interview is over, you will be paid $----. Confidentiality We plan to publish the results of this study, but will not include any information that would identify you or your family members. To keep your information safe, the audiotape of your interview will be placed in a locked file cabinet until a written word-for-word copy of the discussion has been created. As soon as this process is complete, the tapes will be destroyed. The researchers will enter study data on a computer that is password-protected. To protect confidentiality, your real name and any family members name will not be used in the written copy of the discussion. The researchers plan to keep de-identified study data to use for future research about --------------. There are some reasons why people other than the researchers may need to see information you provided as part of the study. This includes organizations responsible for making sure that the research is done safely and properly, including ݮƵ, government research offices, or the study sponsor __________. Also, if you tell us something that makes us believe that you or others have been or may be physically harmed, we may report that information to the appropriate agencies. Contact information If you have questions about this research, including questions about the scheduling of the interview or your payment for participating, you can contact Researcher X, ݮƵ, Department of ----------, 9301 S. King Dr, Chicago, IL 60628, (773) phone number, researcherx@csu.edu. You can also contact his/her faculty advisor, ----------------, Ph.D., ݮƵ, Department of --------, address, Chicago, IL 60628, (773) phone number, faculty advisor@csu.edu. If you have any questions about your rights as aresearch participant, please contact the ݮƵ Institutional Review Board, 9501 S. King Drive, Cook Administration Building j#304-AChicago, IL 60628, (773) 995-2504, irb@csu.edu. Assent By signing this document, you are agreeing to be in the study. We will give you a copy of this document and will keep a copy in our study records. Be sure that we have answered your questions about the study and you understand what you are being asked to do. You may contact the researcher if you think of a question later. 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