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Safe Dates Parental Informed Consent Form

Please read and complete the form at the bottom of the page

Dear Parents/Guardians:                                                

As a part of your child’s educational curriculum, they will be participating in the Safe Dates prevention program for dating abuse. Safe Dates is a 6 week educational program that will be facilitated by educators from the Safe Center of Bethpage, NY. The focus of Safe Dates is to teach high school students about healthy relationships and signs of relationship abuse in order to prevent relationship abuse.

Research Purpose: We, faculty members from the School of Social Work at Adelphi University, would like to request permission for your child to participate in a study on the effectiveness of the Safe Dates program.

Description of research: If you agree, your child will take a survey before and after the Safe Dates sessions about topics such as relationship knowledge, relationship abuse and seeking help for relationship issues.  The surveys are expected to take about 15-20 minutes to complete. Additionally, you or your child will be contacted by Adelphi University researchers by email 6 months after they completed the Safe Dates program to answer a final survey.  This survey will be online and take approximately 15-20 minutes to complete.

Potential benefits: We hope to use what we learn from the study to make changes to this program so it will more effectively help high school students learn about healthy relationships, relationship abuse and help-seeking behaviors.

Potential risks: There is minimal risk if your child agrees to participate.  The study will be explained in language that your child can understand, and your child will participate only if he or she is willing to do so. If your child becomes unhappy or upset in the course of the sessions, their school counselor will be available to talk with them. They will also be given contact information for the Safe Center educator.

Compensation to your child: There is no incentive for taking the first two surveys. Your child will be given a $5 Starbucks gift card for completing the online survey 6 months after they complete Safe Dates. The gift card will be sent electronically to your child’s email address.

Contact Person: If you have any questions about the surveys or study, please contact the Adelphi University faculty evaluators: Drs. Star Kyriakakis and/or Chrisann Newransky at 516-877-4413/516-237-8558 or skyriakakis@adelphi.edu & cnewransky@adelphi.edu.

Voluntary: Participation in this study is voluntary.  Your decision whether or not to allow your child to participate will not affect the services normally provided to your child by his or her high school.  Your child’s participation in the surveys will not lead to the loss of any benefits to which he or she is otherwise entitled. Even if you give your permission for your child to participate, your child is free to refuse to participate.  If your child agrees to participate, he or she is free to end participation at any time.  

Confidentiality: We plan to publish the results of this study, but will not include any information that would identify you, your child or other family members.  Only the Adelphi University faculty evaluators will have access to information from your child. Any information that is obtained in connection with this study and that can be identified with your child will remain confidential and will be disclosed only with your permission or as required by law.  Your child will not be identifiable by his/her real names in any written or verbal reports or publications.

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