Adolescent and Young Adult Screening Questionnaire

Indiana University Assent to Participate in Research
Adolescent and Young Adult Centralized Study Screener (Ages 11-13)
IRB Protocol # 12132

The purpose of the survey is to create a list of adolescents and young adults who may qualify to join our studies and might be interested in participating now or in the future.

The person in charge of this survey and the list of participants is Dr. Matt Aalsma with the Adolescent Behavioral Health Research Program at the Indiana University School of Medicine.

Why am I being asked to take this screening survey?

Scientists do research to answer important questions that might help change or improve the way we do things in the future. Usually, we need to ask people some questions to see if they qualify to join the study – this is called a “screening survey.” This consent form will give you information to help you decide whether you want to take this screening survey. Please read this form, before agreeing to take the survey.

What will happen during this screening survey?

If you want to participate in this screening survey, you will complete a short survey that will determine if you are qualified to participate in one or more of our group’s research studies. If you are qualified to participate in a study, you will be contacted within 2 weeks, and receive information about the study so you can decide if you would like to participate. If you are not eligible to participate, your information will be erased from our database.

Are there any bad things that might happen when you complete this screening survey?

Sometimes bad things happen to people who participate in research. These bad things are called “risks.” The risk of participating in this screening survey is a possibility of breach of confidentiality if someone outside the screening survey team gains access to your information. To reduce this risk, we will store your information in a secure database for only two (2) weeks. After two (2) weeks, your information will be erased from our database. Your answers to this screening survey are confidential, only research staff will be allowed access to them. We will NOT share your survey responses with others outside of our research group, including your parents.

We will protect your information and make every effort to keep your personal information confidential, but we cannot guarantee absolute confidentiality. Your personal information may be shared outside the research team if required by law. We also may need to share your records with other groups who supervise research and interaction with research participants. These groups include the Indiana University Institutional Review Board or its designees, and state or federal agencies who may need to access the research records (as allowed by law).

Are there any good things that might happen when you complete this screening survey?

Sometimes good things happen to people who participate in research. These good things are called “benefits.” The benefit of taking this survey is the potential opportunity to participate in research studies.

Will I get money or payment for answering this screening survey?

You will not get any money for completing this survey. However, if your answers indicate you are eligible for a research study, and you choose to participate in it, that study may provide compensation (money) for your time.

Who can I ask if I have any questions?

If you have questions or encounter a problem, you can contact our research group, the Adolescent Behavioral Health Research Program, by e-mailing bhp@iupui.edu, or calling 317-278-7141. Also, if you have any questions that you didn’t think of now, you can ask later.

What if I don’t want to answer the screening survey?

If you don’t want to answer this screening survey, you don’t have to. It’s up to you. If you complete the survey and decide later that you do not want to be in our database of potential research participants, that’s OK. All you have to do is tell us that you don’t want to be in it anymore by e-mailing bhp@iupui.edu, or calling 317-278-7141, and we will immediately erase your survey responses. No one will be mad at you or upset with you if you don’t want to be in it.

PARTICIPANT’S ASSENT
In consideration of all of the above, I agree to participate in the screening survey and join the list of potential research participants. I will be given a copy of this informed consent document to keep for my records.

Indiana University Assent to Participate in Research
Adolescent and Young Adult Centralized Study Screener (Ages 14-17)
IRB Protocol # 12132

The purpose of the survey is to create a list of adolescents and young adults who may qualify to join our studies and might be interested in participating now or in the future.

The person in charge of this survey and the list of participants is Dr. Matt Aalsma with the Adolescent Behavioral Health Research Program at the Indiana University School of Medicine.

Why am I being asked to take this screening survey?

Scientists do research to answer important questions that might help change or improve the way we do things in the future. Usually, we need to ask people some questions to see if they qualify to join the study – this is called a “screening survey.” This consent form will give you information to help you decide whether you want to take this screening survey. Please read this form, before agreeing to take the survey.

What will happen during this screening survey?

If you want to participate in this screening survey, you will complete a short survey that will determine if you are qualified to participate in one or more of our group’s research studies. If you are qualified to participate in a study, you will be contacted and receive information about the study so you can decide if you would like to participate. If you do not qualify for any studies right now, we will keep your information for up to five (5) years and contact you in the future if we have a new study that you qualify for. You may choose for us to keep your information for less than five (5) years.

Are there any bad things that might happen when you complete this screening survey?

Sometimes bad things happen to people who participate in research. These bad things are called “risks.” The risk of participating in this screening survey is a possibility of breach of confidentiality if someone outside the screening survey team gains access to your information. To reduce this risk, we will store your information in a secure database for only as long as you allow us. Your answers to this screening survey are confidential, only research staff will be allowed access to them. We will NOT share your survey responses with others outside of our research group, including your parents.

We will protect your information and make every effort to keep your personal information confidential, but we cannot guarantee absolute confidentiality. Your personal information may be shared outside the research team if required by law. We also may need to share your records with other groups who supervise research and interaction with research participants. These groups include the Indiana University Institutional Review Board or its designees, and state or federal agencies who may need to access the research records (as allowed by law).

Are there any good things that might happen when you complete this screening survey?

Sometimes good things happen to people who participate in research. These good things are called “benefits.” The benefit of taking this survey is the potential opportunity to participate in research studies.

Will I get money or payment for answering this screening survey?

You will not get any money for completing this survey. However, if your answers indicate you are eligible for a research study, and you choose to participate in it, that study may provide compensation (money) for your time.

Who can I ask if I have any questions?

If you have questions or encounter a problem, you can contact our research group, the Adolescent Behavioral Health Research Program, by e-mailing bhp@iupui.edu, or calling 317-278-7141. Also, if you have any questions that you didn’t think of now, you can ask later.

What if I don’t want to answer the screening survey?

If you don’t want to answer this screening survey, you don’t have to. It’s up to you. If you complete the survey and decide later that you do not want to be in our database of potential research participants, that’s OK. All you have to do is tell us that you don’t want to be in it anymore by e-mailing bhp@iupui.edu, or calling 317-278-7141, and we will immediately erase your survey responses. No one will be mad at you or upset with you if you don’t want to be in it.

PARTICIPANT’S ASSENT
In consideration of all of the above, I agree to participate in the screening survey and join the list of potential research participants. I will be given a copy of this informed consent document to keep for my records.

INDIANA UNIVERSITY INFORMED CONSENT STATEMENT FOR RESEARCH

Adolescent and Young Adult Centralized Study Screener
IRB Protocol # 12132

You are being asked to take a survey to see if you are eligible for a research study or studies. Scientists do research to answer important questions that might help change or improve the way we do things in the future. Usually, we need to ask people some questions to see if they qualify to join the study – this is called a “screening survey.” This consent form will give you information to help you decide whether you want to take this screening survey. Please read this form, before agreeing to take the survey.

All research is voluntary. You can choose whether you want to participate in the screening survey. You will not be penalized or lose any benefits if you decide not to participate or change your mind once you started the survey.

The purpose of the survey is to create a list of adolescents and young adults who may qualify to join our studies and might be interested in participating now or in the future.

The person in charge of this survey and the list of participants is Dr. Matt Aalsma with the Adolescent Behavioral Health Research Program at the Indiana University School of Medicine.

If you want to participate in this screening survey, you will complete a short survey that will determine if you are qualified to participate in one or more of our group’s research studies. If you are qualified to participate in a study, you will be contacted and receive information about the study so you can decide if you would like to participate. If you do not qualify for any studies right now, we will keep your information for up to five (5) years and contact you in the future if we have a new study that you qualify for. You may choose for us to keep your information for less than five (5) years.

Before agreeing to participate, please consider the risks and potential benefits of taking part in this screening survey. The risk of participating in this screening survey is a possibility of breach of confidentiality if someone outside the screening survey team gains access to your information. To reduce this risk, we will store your information in a secure database for only as long as you allow us. Your answers to this screening survey are confidential, only research staff will be allowed access to them. We will NOT share your survey responses with anyone outside of our research group, including your parents.

There is also a potential benefit to participating. The benefit of taking this survey is the potential opportunity to participate in research studies.

You will not be paid for participating in this screening survey. You will not get any money for completing this survey. However, if your answers indicate you are eligible for a research study, and you choose to participate in it, that study may provide compensation (money) for your time.

We will protect your information and make every effort to keep your personal information confidential, but we cannot guarantee absolute confidentiality.

Your personal information may be shared outside the research team if required by law. We also may need to share your records with other groups who supervise research and interaction with research participants. These groups include the Indiana University Institutional Review Board or its designees, and state or federal agencies who may need to access the research records (as allowed by law).

If you have questions or encounter a problem, you can contact our research group, the Adolescent Behavioral Health Research Program, by e-mailing bhp@iupui.edu, or calling 317-278-7141.

For questions about your rights, to discuss problems, complaints, or concerns about a research study, or to obtain information or to offer input, please contact the IU Human Research Protection Program office at 800-696-2949 or at irb@iu.edu.
If you decide to participate in this survey, you can change your mind at any time in the future. If you complete the screening survey and decide later that you do not want to stay on the list of potential research participants, that’s OK. All you have to do is tell us that you don’t want to be in it anymore by e-mailing bhp@iupui.edu, or calling 317-278-7141, and we will immediately delete your information.

PARTICIPANT’S CONSENT
In consideration of all of the above, I agree to participate in the screening survey and join the list of potential research participants. I will be given a copy of this informed consent document to keep for my records.