Parental Informed Consent Form for:

“People Who Self-Injure”

  PARENTAL PERMISSION FORM

Revised May 2005

 Please read the following material that explains the research study in which your child is being asked to participate. Signing this form will indicate that you have been informed about the study and that you give permission for your child to participate. I want you to understand what your child is being asked to do and what risks and benefits, if any, are associated with the study. 

 Once you provide your permission, your child will also be asked to provide his or her assent to participate. Your child may not participate in the study unless BOTH you and your child agree.

 I, Patti Adler, am a faculty member at the University of Colorado , Boulder . I would appreciate your helping me out in my study on people who cut themselves. If you ever want to contact me about my study, you may reach me at the University of Colorado , Department of Sociology, 327 UCB, Boulder , CO 80309-0327 , 303 492-1177. Another excellent way to contact me is by email at: Adler@colorado.edu.

 Project Description: I am interested in learning more about the phenomenon of people who cut themselves. I would like to know more about why people do this, how it feels at the time, and how it affects them subsequently. In particular I am curious to know how people come to do this, if there is a subculture that supports it, why this gives some people a sense of relief, and how they then have to manage the information about this behavior with others. I would like to know how it affects them when they reveal this information to others or when others find out about it.

 Procedures: I would like to talk to your child about this and to tape-record our conversation. I hope you will permit your child to share some of his or her experiences and thoughts with me on this matter. Depending on how much he or she has to say, our conversation is most likely to take anywhere from 45 minutes to two hours. Together we can arrange a mutually convenient time for us to talk. If we are in the same town, he or she and I can meet in my office where we can chat in privacy and without interruption. If you live far away from me, your child and I can conduct our conversation on the telephone, if that is okay with you.

 Risks and Benefits: There are some potential risks your child may encounter from doing this interview. Your child may talk about things that stress him or her. Your child may find discussing the self-injury a sensitive and emotional subject. We may venture into difficulties your child has in managing his or her behavior with others and his or her feelings about that. Your child may worry that I will judge him or her or think less of him or her for this practice. Please be assured that this is not the case. Your child’s behavior, while non-conformist, is not illegal or immoral. My goal is to understand this behavior, not to judge anyone. If your child feels that he or she need further help, I am happy to help him or her find someone good to talk to in your area. I have a list of counselors in Boulder specifically trained to deal with this topic that I am happy to share with your child. If there are any subjects your child would prefer not to talk about, he or she can just say so and we can go on to another subject. Everything that your child says will be held in the strictest confidence. There will be no compensation, nor will there be any costs incurred (including long distance telephone charges), for this interview.

  Initial ____________________

Study Withdrawal: If you decide to let your child participate in this project, please understand that this participation is voluntary and that your child has the right to withdraw consent or to discontinue participation at any time. Your child has the right to refuse to answer any question(s) for any reason.

 Confidentiality: In addition, I will maintain the privacy of the experiences your child discusses in all published and written data resulting from this study. Sociologists are interested in trends and patterns of behavior rather than individual accounts, and I will use pseudonyms to disguise the identity of my subjects as a confidentiality measure.

 I will be tape recording our conversations so that I can remember most accurately what your child has said. Please be assured that I will keep these data in the most secure location, locked in my office, and that they will be destroyed when I have finished with this research. I will shred my notes, and erase over any tapes with a demagnetizer.

 Invitation for Questions: If you or your child have any questions about this study, you should ask me them before you sign this permission form. If you have any questions regarding your child’s rights as a subject, any concerns regarding this project, or any dissatisfaction with any aspect of this study, you may report them – confidentially, if you wish, -- to the Executive Secretary, Human Research Committee, Graduate School, 026 UCB, Regent 308, University of Colorado, Boulder, CO 80309-0026, or by telephone to 303 492-7401. Copies of the University Of Colorado Assurance Of Compliance to the federal government regarding human subject research are available upon request from the Graduate School address listed above.

I have read this paper about the study or it was read to me.  I know the possible risks and benefits.  I know being in this study is voluntary and that my child has the right to decline to participate or to withdraw his or her assent at any time during the study.  I give permission for my child to be in this study.   I have received, on the date signed, a copy of this document containing 2 pages.

 Name of Participant (printed) ______________________________________________

 Name of Parent or guardian (printed) ________________________________________

Signature of Parent or guardian _____________________________ Date ___________

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