BreakThru Secondary Student Consent (Under 18) for New Students

I agree to participate in the National Science Foundation research project titled “The Georgia STEM Accessibility Alliance (BreakThru)” conducted by Noel Gregg , University of Georgia (706-254-2334) and Robert Todd, GaTech (404-894-9865). I understand that my participation is voluntary. I can refuse to participate or stop taking part at any time without giving reason and without penalty or loss of benefits to which I am otherwise entitled. If I decide to withdraw from the study, the information that can be identified as mine will be kept as part of the study and may continue to be analyzed, unless I make a written request to remove, return, or destroy the information. My decision to participate or not, and the decision to withdraw, if applicable, will not affect my grades or class standing.

The purpose of this program is to increase the number of students with disabilities that pursue degrees in STEM (Science, Technology, Engineering, or Math). If I volunteer for this project, I will be asked to do the following:

• Participate in a training session on how to navigate in a virtual world and the code of conduct for all virtual world activities. This will take approximately 1 hour.
• Participate in virtual mentoring activities approximately one hour per week for a minimum of 20 hours per academic year.
• Participate in virtual learning activities and STEM field trips. This will take up to 3 hours per academic year.
• Allow my school to share data collected in the school with project personnel. All data will be kept in a secure location. It will only be viewed by project personnel as it pertains to the BreakThru project activities.
• Provide demographic and academic achievement information
• Allow the information I provided on my BreakThru application to be used for research purposes.
• Allow collecting my participation in project activities (frequency, duration, activity selection, level of participation in on line mentoring and the virtual learning community) to be recorded for research purposes.
• Respond to project surveys; this will take approximately 2 hours per year.

The total time I will be expected to participate for the BreakThru project each academic year is 26 hours. However, I may spend additional time of my own choosing in the virtual world because it will be open year-round.

For my participation, I will receive $75 per semester. In order to receive the financial incentive, I must provide my name, social security number, citizenship, and address on the incentive form. Payment will be mailed to me at the end of each semester. The identifiable information I provide will be kept confidential and separate from other BreakThru materials. The information will be used only for the purpose of payment and will be seen by the BreakThru account manager and the University of Georgia Business Office.

The benefits for me are that I will be receiving support and expert guidance on STEM material that may help me in my classes. I will also be providing information on the use of virtual worlds and social networks for educational purposes. My feedback on the surveys will shape a model. This model can be put in place in other school systems across the nation.

No risk or harm is expected. I must have a signed parental permission form in order to participate. I understand that any information that identifies me or can be linked to me will be held in the strictest confidence legally possible. There are four conditions under which BreakThru staff may breach confidentiality: 1) imminent risk of doing serious harm to myself; 2) imminent risk of doing harm to others; 3) victim of physical or sexual abuse; or 4) mandated by a judge in a court of law. I understand that information may be shared with my parents or guardians without being considered breaking confidentiality. Virtual communications are insecure and there is a limit to the confidentiality that can be guaranteed due to the technology itself. However, chat transcripts will be coded and identifying information will be removed. Codes will be kept for three years after the completion of the program, but deleted at the end of that period of time so that the data can no longer be linked back to me. My identity will be coded. My data will be kept in a secured location.

The BreakThru project activities are not regular services offered by my high school. I understand that I will continue to receive all services at my high school whether I decide to participate or not in this project. The researchers will answer any further questions about the research, now or during the course of the study.

By check the box below and submitting this form on-line you are agreeing to take part in the research study described above. Please print a copy of this form for your records.