Institutional Review Board: Policy and Procedure Manual

Institutional Review Board

Sample Consent Form


NOTE: Each page must be on Wofford College letterhead except in cases of collaborative projects when the letterhead from a hospital, university, etc. is acceptable. All letterhead must be the original, not a copy.

IRB Approval #___

STUDENT CONSENT FORM (GC Condition)  

Funding Source: National Institute of Alcohol Abuse and Alcoholism  

Title: THE EFFECTIVENESS OF TEEN ALCOHOL ABUSE INTERVENTION  

Investigators:

Alliston K. Reid, Ph.D., Professor, Department of Psychology, Wofford College, Spartanburg, SC 29301

Office telephone: 597-4642

Description of the Study: The Spartanburg County Public Schools are participating in a research program concerning how to best help adolescents with alcohol and/or drug use concerns. This research is being performed by Dr. Reid and students of Wofford College. Because you were referred for school-based substance abuse assessment, you can participate in this research program. We are contacting you now to seek your consent to take part in this research. Dr. Reid and colleagues are interested in examining how well school-based substance abuse group counseling works for addressing students' alcohol use concerns. Their research program includes three things: (1) thorough substance abuse assessment, (2) participation in school-based substance abuse group counseling, and (3) individual follow-up meetings with a research interviewer. The thorough substance abuse assessment involves you being interviewed and asked to complete questionnaires during three separate 45-minute sessions taking place at school. The school-based group counseling involves you attending ten 45-minute sessions of weekly group substance abuse counseling taking place at school. The individual follow-up meetings involve you being interviewed and asked to complete questionnaires across two separate 45-minute sessions immediately after the completion of group counseling, and again during single 45-minute sessions at both 1-month and 3-months after the completion of group counseling. All assessment and counseling sessions will be scheduled during regular school hours. We will do our best to make sure that these sessions do not interfere with your regular school responsibilities.  

Risks and Benefits to the Participant: By participating in this research program, you will receive more thorough substance abuse assessments than students in your school usually receive. Furthermore, you will also benefit from taking part in school-based substance abuse group counseling. The purpose of this study is to examine the effectiveness of group counseling for addressing students' alcohol use concerns. The information gained from this study may some day improve services that are available to adolescents with alcohol and other drug concerns.

One risk to you is that some people find it uncomfortable to discuss personal problems or participate in group counseling. On the other hand, many teenagers like these kinds of experiences. A second risk concerns a potential loss of privacy. By participating in group counseling at school with other students there is the possibility that another group member may violate your confidentiality by talking about you outside of the group. However, safeguards to protect against this risk will be taken, including a discussion with group members of the importance of respecting each other's privacy and by having the rule "what's said in the group stays in the group." If you have any concerns about your participation in the study, you can discuss them with any project staff member or can contact Dr. Reid at the number listed above.  

Costs and Payments to the Participant: As thanks for taking part in our study, you will receive a $15 gift certificate to a local music shop, sports store, or restaurant (your choice) for each interview that you successfully complete. Neither you, your parents, nor your insurance will be charged for any of the assessment or counseling sessions.  

Confidentiality: Strict confidentiality will be maintained at all times throughout the course of the the research project unless disclosure is required by law. A random code number, rather than your name, will be used to identify information you give to us. Only members of the immediate project staff will have direct access to this information. Reports at scientific meetings or in scientific journals will not include any information which identifies you as a participant in this study.

The counseling sessions will be taped on a cassette player. The purpose of these tapes is to grade the performance of the counselor conducting the group sessions. The counselor will only use the first names of group participants during the taping to protect the confidentiality group members. Again, only members of the immediate project staff will have direct access to these tapes. The tapes will be erased immediately after the counselor's performance has been graded.

As noted in the "Risks and Benefits" section above, there is the possibility that another group member may violate your confidentiality by talking about you outside of the group. However, safeguards to protect your confidentiality will be taken, including a discussion with group members of the importance of respecting each other's privacy and by having the rule "what's said in the group stays in the group."

In certain situations, it may be necessary to share some of the information provided by you with your parents. We will contact your parents only if we believe that there is a high risk that something bad could happen to you if we don't let your parents know what is going on. Such situations include (a) extremely frequent and heavy use of alcohol and/or other drugs, (b) engaging in dangerous behavior like drinking while driving, (c) thinking seriously about killing yourself, (d) extreme feelings of anxiety, depression, or confusion, or (e), if you're female, pregnancy. We will limit the information we share with your parents to only the reasons why we're concerned about you.

There is one additional exception to confidentiality that you should know about. Your research records, just like any clinic records, may be subpoenaed by court order or may be inspected by federal regulatory authorities.  

Participant's Right to Withdraw from the Study: You may choose to not participate or to stop participation in the research program at any time without penalty or loss of Spartanburg County Schools Substance Abuse Prevention Program benefits. This means that you can refuse to participate in the study, yet still receive the regular substance abuse prevention and assessment services available through the school. If you choose not to participate, the information collected about you will be destroyed.  

Voluntary Consent by Participant: Participation in this research project is totally voluntary, and your consent is required before you can participate in the research program.


I have read the preceding consent form, or it has been read to me, and I fully understand the contents of this document and voluntarily consent to participate. All of my questions concerning the research have been answered. I hereby agree to participate in this research study. If I have any questions in the future about this study they will be answered by the investigators listed above or their staff. A copy of this form has been given to me.  

Participant's Signature:__________________________ Date:__________________

Witness's Signature:_____________________________ Date: __________________

Return to IRB Consent Form