Parent Consent Form for Online Survey

INTRODUCTION

We are asking for your permission for your child to be in a research study so that we can learn new information that mayhelp others. If you decide not to give your permission for your child to be in this study, there will be no consequences. If you decide to allow your child to be in this study, you/your child may change your mind at any time during the study and your child can stop being in the study. Take all the time you need to make your choice. Ask us any questions you have. Itis also okay to ask more questions after you decide to allow your child to be in the study. You/your child can ask questions at any time.
WHO SHOULD NOT BE IN THE STUDY

Your child cannot be in this study if they:
· DO NOT identify as Black, African American or Multiracial Black/African American
· ARE NOT in aged 10 - 18 years old
· DO NOT attend school outside of the home

WHAT WILL HAPPEN IN THE STUDY?

If your child qualifies, and you decide you want your child to be in the study, your child will then be asked if they wish to participate. If they wish to participate in the study, below is what will happen:

Your child will be asked to complete an online survey using a link. The beginning questions will ask for information about your child’s background (e.g., gender identity, race/ethnicity). The other survey questions will ask your child about what happens to them and/or their peers at school and how they feel about these events (Sample questions: “People act as if they’re better than you are,” “In the last month, how often have you felt that things were going your way?,” I felt lonely,” “Doing well in school is important to my future,” “I believed my teachers would help me if I told them something was wrong at school, “and “I have seen another Black student at my school Bullied because they are Black”) You will have to read each survey question and select a response from multiple choices that is the best answer for you. There will be no right or wrong answers for the survey questions.

Each survey should take about 25 minutes to complete.

WHAT ARE THE GOOD THINGS THAT CAN HAPPEN FROM THIS RESEARCH?

Being in this study may not help your child right now but will help the research team learn more about how to better measure what happens to students at school in order to create fair and equitable school environments.

WHAT ARE THE BAD THINGS THAT CAN HAPPEN FROM THIS RESEARCH?

Your child may be asked questions that make them uncomfortable or bothered (e.g., school experiences with racism and/or discrimination, perceptions of stress). Your child will not need to answer any questions that theydo not wish to and can stop participating in the study at any time. If they become very upset, we will end their participation. We will also offer to have your child speak to someone about what they are feeling. We will also tell you about any problems.

There may be other risks that we do not know about yet.

You or child’s relationship with their school or school district or Winston-Salem State University will not be impacted by participating or not participating in this research study.

WHAT OTHER CHOICES ARE THERE?

Instead of being in this study, you can choose not to have your child be in it.

HOW WILL INFORMATION ABOUT YOUR CHILD BE KEPT PRIVATE?

Making sure that information about your child remains private is important to us. To protect your child’s privacy in this research study we will:

1. Your child will be assigned a study number. We will keep a master list with ID numbers and names, but this will only be available to the primary researchers and will be kept in a location separate from the data, in a password protected file.

2. Your child’s responses to survey items will be entered electronically. All data will be password protected.

3. Researchers will probably publish the results of this study in places such as academic journals or research conferences. They may also include a summary of the findings in grants to the grant funders listed at the top of this consent form. No one will be able to tie this information to you or your child.

WHAT IF WE LEARN NEW INFORMATION DURING THE RESEARCH?

The research team will tell you if they find out about new information from this or other studies that
WILL YOU/YOUR CHILD BE PAID TO BE IN THIS RESEARCH STUDY?

As a thank you for your time, your child will receive $25 in the form of an electronic gift card sent to the email address provided to us by you (below) or your child (on their assent form).

HOW WILL RESEARCH DATA BE STORED AND WHO WILL HAVE ACCESS?

Data will be stored on cloudbased system, (ie: sharepoint or OneDrive), which are both password protected systems accessible only to the research team during the course of the project. In addition, data files will be stored on local computers (also password protected) in the primary researcher’s personal research facility. The research team, the study sponsors (National Science Foundation and Chan Zuckerberg), and regulatory entities such as the Office of Human Research Protections (OHRP), may have access to study records to protect your safety and welfare. Any information derived from this research project that personally identifies your child will not be voluntarily released or disclosed by these entities without your separate consent, except as specifically required by law (i.e., if your child stated they would harm themselves or someone else). Publications and/or presentations that result from this study will not include identifiable information about your child.

WHO DO YOU CALL IF YOU HAVE QUESTIONS OR PROBLEMS?

For questions, concerns, or complaints about this research study you can contact the researchers listed on page 1 of this document. If you would like to talk to someone that is not part of the research staff, or if you have general questions about your research study rights or questions, concerns, or complaints about the research, you can call the Winston-Salem State University Institutional Review Board (IRB):

Winston-Salem State University IRB Contact: Compliance Officer in the Office of Sponsored Programs and Research
o Phone: (336) 750-2000,
o Email: holtse@wssu.edu
o In person: 601 Martin Luther King Jr. Drive, Winston-Salem, NC 27110

CAN YOU CHANGE YOUR MIND?

Participation in this study is voluntary and there is no penalty for not participating. You are free to withdraw your child’s participation after granting permission and/or your child may withdraw at any time after the study has begun without penalty (i.e., your child will still receive their $25 compensation). In the event that your child withdraws from this study, the information your child has already provided will be kept in a confidential manner. What you/your child decides won’t make any difference with your grades or about how people think about you/your child.

WILL THIS PERMISSION EXPIRE?

Your permission will expire at the end of the study. If the study involves the creation or maintenance of a research database repository, this authorization will not expire.

SIGNATURES

My signature indicates that I agree to allow my child to be in this study and have been told that my child will be allowed to withdraw from this study at any time without penalty.

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* 1. Printed Name of Youth Research Participant

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* 2. Youth Age

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* 3. Youth Grade

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* 4. Name of Parent/Legally Authorized Representative

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* 5. Parent/Legally Authorized Representative Cell Number

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* 6. Parent/Legally Authorized Representative Email Address

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* 7. Please enter today's date

Date

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* 8. Email Address Where Gift Card Should Be Sent

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* 9. How would you prefer your child to receive the survey link?

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