PARENT’S INFORMED CONSENT FOR YOUTH FOCUS GROUP PARTICIPATION

Why are we asking for your permission?

Your child is invited to participate in a focus group to help us better understand the health and
safety needs of young people in this community. His or her participation in this focus group is
voluntary. The Bear River Band would like to include the youth perspective on issues they view
as problems for them so that we may seek funding for special programs tailored to their age
group.

FOCUS GROUP FACILITATION—Who can I talk to about the focus group?

For specific questions about this study, you may contact Dawn Arledge, Director of Health
Research at the California Center for Rural Policy, (707.826.3400) or the program principal
investigator, Connie Stewart, California Center for Rural Policy (707.826.3402).

PURPOSE OF THE FOCUS GROUP—What will be asked?

The focus group will ask youth to answer questions to help us better understand what
difficulties they are facing in their community, such as how they view healthy and unhealthy
lifestyles, what they do for fun, how safe they feel in their community, and whether or not they
have had interactions with law enforcement. The focus group consists of 8 questions.

PROCEDURES INVOLVED IN PARTICIPATING IN THE FOCUS GROUP—what will your child have
to do?
If you agree to let your child volunteer to participate in this focus group, here is what he or she
will be asked to do: Participate with other youth in a 45-60 minute focus group with 8
questions. The focus group will take place at the Rohnerville Rancheria after school hours. The
staff researchers will make an audio recording of the focus group in order to transcribe the
information accurately. Audio recordings and focus group notes will be stored under lock and
key. Your name will not appear on recordings or interview notes.

POTENTIAL RISKS—what are the risks and possible problems if your child takes part in this
focus group?
The possible risk involved may be temporary feelings of emotional discomfort related to the
topics of personal safety and health. We will provide resource guides to all participants that
describe services in the community that can help people seek help for some of the issues that
may be discussed, such as Victim Advocates, Humboldt Rape Crisis Center, United Health Indian
Services, etc. In addition, the event facilitators are trained to help youth participants be
comfortable and feel supported.

POTENTIAL BENEFITS—how will this program evaluation help your child?

Youth who are members of the Bear River tribe will have the opportunity to provide input to the
tribe about the problems that youth in the community face. They may also suggest services or
programs that would help them with these issues that the tribe may then develop for them.

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 PARENT’S INFORMED CONSENT FOR YOUTH FOCUS GROUP PARTICIPATION

PAYMENT FOR PARTICIPATION—What will my child receive?

Focus group participants will have their phone numbers placed into a raffle for three possible
prizes: a $100 Visa gift card, a $50 Visa gift card, and a $25 Visa gift card. You can participate
in the raffle even if you do not complete the study by asking the investigator to include you.

CONFIDENTIALITY– Who will know about what my child says?

Your child’s identity will not be linked to any information they provide as part of this study. If
results are shared with grant funders in a narrative about the tribe’s needs, his or her name will
be kept private. We will make every effort to keep your child’s answers confidential. However,
because staff researchers must follow mandated reporting rules, information or concerns your
child shares about abuse or neglect of any minor are reportable under California’s Child Abuse
and Neglect Reporting Act (CANRA).

PARTICIPATION AND WITHDRAWAL—Can my child stop answering if he or she doesn’t want to

continue?
Your child’s participation in this focus group is VOLUNTARY. His or her decision whether or not
to participate will not affect his or her relationship with the school or any community programs.
If you give permission for your child to participate, he or she is free to withdraw consent and
discontinue participation at any time.

NAME OF PROGRAM EVALUATOR—Who can I talk to about the focus group?

For specific questions about this study, you may contact Dawn Arledge, Director of Health
Research at the California Center for Rural Policy (707.826.3400), or the program principal
investigator, Connie Stewart, California Center for Rural Policy (707.826.3402).

RIGHTS OF PARTICIPANTS IN THE PROGRAM EVALUATION—What are my rights as a

parent/guardian and my child’s rights?
You or your child may withdraw consent at any time and discontinue participation without
penalty. Your child is not waiving any legal claims, rights or remedies because of his or her
participation in this focus group.

You may withdraw consent at any time and discontinue participation without penalty. You are
not waiving any legal claims, rights or remedies because of your participation in this program
evaluation. If you have any concerns or any dissatisfaction with any part of this study, you may
contact the Institutional Review Board for the Protection of Human Subjects
at irb@humboldt.edu or 707.826.5165.

Approval Date

This form was approved in November 2019 for use for one year.

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 PARENT’S INFORMED CONSENT FOR YOUTH FOCUS GROUP PARTICIPATION

Permission by Parent / Guardian for Child to Participate

I have read and understood what it means for my child to participate in the focus group. By
signing this informed consent form, I give permission for my child or ward to be a part of this
focus group. I will receive a copy of the consent form.

____________________________ __________
Printed Name of Parent/Guardian Signed Name of Parent/Guardian Date

_______________________________
Phone Number for Parent/Guardian

_________________________________ ________________________________ ________

Printed Name of Tribal Representative Signed Name of Tribal Representative Date