Survey Consent Information Form

Dear Parent/Guardian,

 

We are seeking participation from young people across the state of Colorado ages 12-20 to complete an online survey to evaluate a Youth Marijuana Prevention Media Campaign for the Colorado Department of Public Health and Environment. The purpose of the survey is to get youth opinions about marijuana use and media ads. These opinions will help inform an educational campaign to prevent marijuana use among Colorado youth. The survey is being conducted by OMNI Institute, a Colorado-based nonprofit research and evaluation firm (www.omni.org). Many young people across Colorado are being asked to participate in the online survey, which will only take about 15 minutes to complete.

 

The survey asks questions about: consequences from using marijuana, reasons why some youth might use marijuana, and prevention ads. There are also questions about your child’s demographics, such as race, age, and gender. The survey is completed online and is anonymous. To ensure only those youth under 18 who have parental permission are provided access to the survey, we will only use the information you provide below to send the online survey to you and/or your youth. 

 

We will not collect your child’s name or any other personal information. Data from your child will be combined with data from other youth. Only these combined results will be shared. All information will be kept confidential. Only designated staff will have access to the data which is stored on secure, password-protected servers at the OMNI Institute.

 

The results of this evaluation will help inform marijuana prevention efforts in Colorado. Your child will have two chances to win $250 for participating in the survey. Your child’s contact information for the drawing (which only needs to include an email address or other preferred contact information) will be collected in a separate location and can never be linked to their survey responses.

 

Your child's participation is 100 percent voluntary. Your child may choose not to participate in the survey or may stop at any time. It is okay for your child to leave questions blank. You may choose not to have your child participate in the survey. If you do not consent to your child participating in the survey, you do not need to provide any information and can exit this page now.

 

If you have any questions about the study or this consent form, please don’t hesitate to contact Dr. Jean Denious, CEO at OMNI Institute and Lead Evaluator for this project.  She can be reached at jdenious@omni.org or 303-839-9422, x121.

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* 1. ELECTRONIC SIGNATURE: By pressing “I give permission” button below, I confirm that I understand the purpose of the research and the study procedures. My signature below indicates my willingness to let my child participate in this study.

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* 2. Parent/Guardian Electronic Signature: 

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* 3. Parent's Email Address:

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* 4. Child's Email Address:

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* 5. Today's Date:

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