Delta Futures 3 Consent Form

Delta Futures 3 program will implement multiple curricula with supplemented preconception topics, promoting Health Among Teens-Abstinence Only and serve expectant/parenting teens. During small interactive group sessions, participants will receive information on HIV and other sexually transmitted infections, learn communication and decision-making skills, and receive instruction on contraceptive methods and develop sexual risk-reduction skills. The focus for expectant/parenting teens shall be birth spacing and reducing STIs so that the adolescent can focus on successfully completing their education.

You are being asked to participate in the program, which is part of a research study. As part of your participation, DHA staff will gather and keep information on you, including enrollment information, survey, and information on your health. Program staff may also use information found through screening to connect you to services through a referral for further support. If this happens, the program staff member will help you follow through on suggested referrals. This is a research project and you have a right to not answer any or all questions or take part in any or all the screenings.

Results will be kept private and will only be used to inform referrals, program effectiveness and research. You are welcome to look at your records, including the results of all evaluations, at any time. Only group information, with no personal information, will be shown at any meetings or published. We will make every attempt to keep your information private and information associated with your name will not be available to anyone not directly conducting or evaluating this study. Identifiable information may be shared with the Mississippi Department of Health and the National Strategic Planning and Analysis Research Center (nSPARC) at Mississippi State University for the purpose of evaluating future pregnancy, birth, and
health outcomes. In addition, de-identified data will be shared with DHA’s external evaluator for the purpose of research and evaluation. Information that will be used for evaluation and review purposes does not contain any personally identifiable information. External evaluators include Delta Health Alliance authorized researchers at the University of Memphis.

There are minimal mental or physical risks expected as a result of taking part in this program, and you may stop at any time without getting in trouble. In the event of loss of privacy or other unexpected harm, DHA has
no way to pay anyone for their injury

I hereby give my consent to release program information as deemed beneficial to me and will be an active participant in the process. This Consent Agreement is valid for the duration of the Delta Futures program initiative. Until such time as I withdraw my consent, which must be communicated in writing and addressed to DHA at P.O. Box 150, Indianola, MS 38751 my consent shall remain in place, valid and effective. I have a right to receive a copy of this document. I reserve all rights provided to me by law not waived by the scope of this consent and authorization.

DF3 Consent Form

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