Universal Screening Student Informed Consent Form

Example Template:

The aim of the screening is to better understand mental health risk of each student.

Your participation is voluntary. Your decision whether or not to participate will not affect any relationship you have with the screening professionals or your school. If you decide to participate, you are free to withdraw your consent and discontinue participation at any time without penalty.

The screening will take 10-15 minutes of your time on _____ occasion. The screener will record your answers to each screening question. The screener may take additional notes throughout the screening. Your answers to the screening will be transcribed verbatim. Your name will be attached to the screening data. All screening records will be kept in a secure manner determined by your school.

The risks in participating in this screening are minimal. The screening questions may have the ability to invoke memories or experiences that were unpleasant. There are no financial costs to you for your participation. The deidentified data may be shared with ____, School personnel (i.e. teachers, school counselors, school administration), your School District and Oregon Health Authority.

Your screener is a mandated reporter. Any disclosure of harm to yourself or others will be reported. If you choose to disclose any mental health concerns or distress we may suggest talking to a mental health professional. We can connect you straight away.

If you have any questions, please feel free to contact: _________.

By signing below I / the student certify:

That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the screening procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Name of Student: _________ Student Signature: ___________ Date: _______

For Screener (To be completed at time of informed consent)

I have explained the screening and answered all of the student’s questions. I believe that he/she/they understands the information described in this consent form and freely consents to participate.

Name of Screener: _________ Signature of Screener: ___________ Date: _______