PARENT/GUARDIAN CONSENT
My name is XXX. I am a graduate student in the XXX Program at the University of Illinois at
Springfield. I am conducting research as part of my Master’s project and it will involve the use of surveys. The purpose of this research is to learn about young males’ views of family life and their views about using cigarettes, alcohol, and drugs. I would like your permission to survey your child for this study.
Your child will be asked to complete two surveys. This should require no more than 30 minutes of their time to complete. Please have them complete the survey being careful not to place their name or any identifiable information on the survey. When completed, place the survey in the envelope XXX and return it to XXX.
Your child’s participation in this research is completely voluntary. You have the right to withdraw from this research at any time without negative consequences. If you choose to participate in the research, you do not have to answer any question or questions that make you uncomfortable or that you do not want to answer. You may also withdraw your consent and participation at any time without consequence. The information I gather will not go in any school records. During the research the surveys will be stored securely and remain confidential. The surveys will be destroyed after I tabulate the results. The results will be reported in group format only and no identifiable information will be reported.
If you have questions regarding the study or your participation, you can contact me at XXX. You can also contact my adviser, Dr. XXX, at 217-206-xxxx.
The study has been reviewed by the UIS Human Subjects Review Officer. Dr. James Klein can answer questions about your rights as a volunteer participant in this project. He can be reached at
217-206-6883.
The results of my research will be available XXX (e.g. after July 1). If you would like a copy of the results or have any questions, please contact me at xxx-xxxx or my advisor, Dr. XXX, at 206xxxx. (or list where they will be available)
Please detach this portion and return it to school by XXX
Consent Statement:
I have read the consent and understand my participation is completely voluntary. I know that I can stop my participation at any time with no negative consequences for my child. By signing and dating this document I am consenting to participate in the research.
I voluntarily give permission for
(name)
Signature
Printed Name
Relationship to child: Parent
to participate in this study.
Date
Guardian

HIGH SCHOOL STUDENT ASSENT
My name is XXX. I am a graduate student in the XXX Program at the University of Illinois at
Springfield. I am conducting research as part of my Master’s project and would like your help.
I would like you to complete two surveys. The surveys contain questions about your views of your family life and your attitudes about the use of cigarettes, alcohol, and drugs. The surveys will take about 30 minutes each to complete.
Your participation in this research is completely voluntary. You have the right to withdraw from this research at any time without negative consequences. If you choose to participate in the research, you do not have to answer any question or questions that make you uncomfortable or that you do not want to answer. You may also withdraw your consent and participation at any time without consequence. The information I get will not go in any school records and will not affect your grades at school.
Please complete the surveys and be careful to not place your name or any other identifiable information on the survey. No one at school will see your answers and your answers will be confidential. All surveys will be destroyed after the results are compiled. By completing the surveys, you agree to participate in the research. Please seal your surveys in the enclosed envelope and place them in the box at the front of the room. If you do not wish to complete the surveys, please sit quietly until everyone has finished.
If after taking the surveys you feel you need to talk to someone, please contact XXX (e.g. school counselor). He/she can talk with you about any of the issues that are part of these surveys.
If you have questions regarding the study or your participation, you can contact me at XXX or my adviser, Dr. XXX, at 217-206-xxxx.
The study has been reviewed by the UIS Human Subjects Review Officer. Dr. James Klein can answer questions about your rights as a volunteer participant in this project. She can be reached at 217-206-6883.
Thank you for your participation. Please keep this letter for your records.
Assent Statement:
I have read the assent and understand my participation is completely voluntary. I know that I can stop my participation at any time with no negative consequences. By signing and dating this document I am voluntarily assenting to participate in the research.
Signature
Printed Name Date