Institutional Review Board
Sample Consent Form
IRB Approval #___
STUDENT CONSENT FORM (GC Condition)
Funding Source: National Institute of Alcohol Abuse and Alcoholism
Title: THE EFFECTIVENESS OF TEEN ALCOHOL ABUSE INTERVENTION
Investigators:
Alliston K. Reid, Ph.D., Professor, Department of Psychology, Wofford College,
Spartanburg, SC 29301
Office telephone: xxx-xxx-xxx
Description of the Study: The XXXXXXXX County Public Schools are participating in a
research program concerning how to best help adolescents with alcohol and/or drug use
concerns. This research is being performed by Dr. XXXX and students of Brevard
College. Because you were referred for school-based substance abuse assessment, you
can participate in this research program. We are contacting you now to seek your consent
to take part in this research. Dr. XXX and colleagues are interested in examining how
well school-based substance abuse group counseling works for addressing students'
alcohol use concerns. Their research program includes three things: (1) thorough
substance abuse assessment, (2) participation in school-based substance abuse group
counseling, and (3) individual follow-up meetings with a research interviewer. The
thorough substance abuse assessment involves you being interviewed and asked to
complete questionnaires during three separate 45-minute sessions taking place at school.
The school-based group counseling involves you attending ten 45-minute sessions of
weekly group substance abuse counseling taking place at school. The individual followup meetings involve you being interviewed and asked to complete questionnaires across
two separate 45-minute sessions immediately after the completion of group counseling,
and again during single 45-minute sessions at both 1-month and 3-months after the
completion of group counseling. All assessment and counseling sessions will be
scheduled during regular school hours. We will do our best to make sure that these
sessions do not interfere with your regular school responsibilities.
Risks and Benefits to the Participant: By participating in this research program, you will
receive more thorough substance abuse assessments than students in your school usually
receive. Furthermore, you will also benefit from taking part in school-based substance
abuse group counseling. The purpose of this study is to examine the effectiveness of
group counseling for addressing students' alcohol use concerns. The information gained
from this study may some day improve services that are available to adolescents with
alcohol and other drug concerns.
One risk to you is that some people find it uncomfortable to discuss personal problems or
participate in group counseling. On the other hand, many teenagers like these kinds of
experiences. A second risk concerns a potential loss of privacy. By participating in group
counseling at school with other students there is the possibility that another group
member may violate your confidentiality by talking about you outside of the group.
However, safeguards to protect against this risk will be taken, including a discussion with
group members of the importance of respecting each other's privacy and by having the
rule "what's said in the group stays in the group." If you have any concerns about your
participation in the study, you can discuss them with any project staff member or can
contact Dr. XXXX at the number listed above.
Costs and Payments to the Participant: As thanks for taking part in our study, you will
receive a $15 gift certificate to a local music shop, sports store, or restaurant (your
choice) for each interview that you successfully complete. Neither you, your parents, nor
your insurance will be charged for any of the assessment or counseling sessions.
Confidentiality: Strict confidentiality will be maintained at all times throughout the
course of the research project unless disclosure is required by law. A random code
number, rather than your name, will be used to identify information you give to us. Only
members of the immediate project staff will have direct access to this information.
Reports at scientific meetings or in scientific journals will not include any information
which identifies you as a participant in this study.
The counseling sessions will be taped on a cassette player. The purpose of these tapes is
to grade the performance of the counselor conducting the group sessions. The counselor
will only use the first names of group participants during the taping to protect the
confidentiality group members. Again, only members of the immediate project staff will
have direct access to these tapes. The tapes will be erased immediately after the
counselor's performance has been graded.
As noted in the "Risks and Benefits" section above, there is the possibility that another
group member may violate your confidentiality by talking about you outside of the group.
However, safeguards to protect your confidentiality will be taken, including a discussion
with group members of the importance of respecting each other's privacy and by having
the rule "what's said in the group stays in the group."
In certain situations, it may be necessary to share some of the information provided by
you with your parents. We will contact your parents only if we believe that there is a high
risk that something bad could happen to you if we don't let your parents know what is
going on. Such situations include (a) extremely frequent and heavy use of alcohol and/or
other drugs, (b) engaging in dangerous behavior like drinking while driving, (c) thinking
seriously about killing yourself, (d) extreme feelings of anxiety, depression, or confusion,
or (e), if you're female, pregnancy. We will limit the information we share with your
parents to only the reasons why we're concerned about you.
There is one additional exception to confidentiality that you should know about. Your
research records, just like any clinic records, may be subpoenaed by court order or may
be inspected by federal regulatory authorities.
Participant's Right to Withdraw from the Study: You may choose to not participate or to
stop participation in the research program at any time without penalty or loss of
XXXXXXXXXXXXX County Schools Substance Abuse Prevention Program benefits.
This means that you can refuse to participate in the study, yet still receive the regular
substance abuse prevention and assessment services available through the school. If you
choose not to participate, the information collected about you will be destroyed.
Voluntary Consent by Participant: Participation in this research project is totally
voluntary, and your consent is required before you can participate in the research
program.
I have read the preceding consent form, or it has been read to me, and I fully
understand the contents of this document and voluntarily consent to participate. All
of my questions concerning the research have been answered. I hereby agree to
participate in this research study. If I have any questions in the future about this
study they will be answered by the investigators listed above or their staff. A copy of
this form has been given to me.
Participant's Signature:__________________________ Date:__________________
Witness's Signature:_____________________________ Date: __________________