US2020 Youth Assent Form

US2020 Student Survey 2015-2016
Youth Assent Form

Dear Student:

US2020 is conducting this survey in partnership with your school and/or your after school program, to help us learn about who gets involved in science, technology,engineering, and math (STEM) activities and what activities are good for youth. You were chosen to participate in the survey because you participated in STEM mentoring.

What am I being asked to do?
We are inviting you and other youth to complete a 15-20-minute survey. There are questions on the survey about your participation in activities related to STEM, your background, and how you are doing in school. There are no right or wrong answers and you can leave any question blank that you do not want to answer. You can also stop taking the survey at any time, without getting in trouble.

Taking the survey is your choice
Your parents have given permission for you to complete the survey, but that does not mean you have to take it. If you do not want to take the survey, it will not change your school grades or the activities you participate in at or after school. If you do not want to take the survey, let your teacher know. Your teacher will give you something else to do. It is possible that you might feel upset by some of the questions. If you do feel upset and want to talk to someone about it, contact your school counselor.

Your Information will be kept private
Your answers will be kept private. Your answers will not be shared with your parents or anyone else except people who work on this project at the local city partner and US2020. When US2020 receives your survey, they will take your name off so that it will not be connected with your answers or be used in any reports. No one else but the team who works on the project will see your survey answers.

What are the benefits and risks of taking the survey?
There are no direct benefits or major risks to you by completing the survey. However, your answers will be used to improve STEM activities like the ones you have participated in.

If you have questions, please call Adriana Lopez at (804) 404-5317. If you have questions or concerns about the survey, you may contact Dana Gonzales, our Institutional Review Board contact, at 855-226-4472 (toll free) or

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* 1. Please check the box below that indicates if you will participate in the survey project. Checking a box indicates that if you had any questions, they have been answered and you understand what you are being asked to do.

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* 2. First and Last Name

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* 3. Today's Date (MM/DD/YYYY)