Listening Circle Assent Form

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Appalachian shOUT, which stands for Appalachian Sexual Health Outreach, is a collective impact initiative in
Northeast, Tennessee, and Southwest, Virginia, that aims to engage community systems to support youth wellbeing and sexual health. Listening Circles are the first step in this work.

Listening Circles give participants a chance to share their lived experience without contradiction or judgment. They support honesty and nurture compassion in an atmosphere of safety and equity. We hope they will help us better understand the needs of Appalachian youth and how we can all empower them with information and support to make informed decisions about their health.

You can expect open ended questions about the challenges, barriers, and messages you experience about sexual and overall health. You will not be forced or pressured to answer any questions you are not comfortable with, and no direct questions will be asked about your own behaviors.

Participation in the listening circles is completely voluntary and confidential, and you may leave the session at any point if you are uncomfortable. Notes will be taken during the session; however, no personally identifying information will be recorded. Lessons learned and themes from the listening sessions will be included in the final listening project report.

All of the responses that are given as part of the listening circle will be kept private. They will only be available to people involved with the project, except when required by law. There are two exceptions: 1) if a minor reveals that they are a danger to themselves or others; 2) if they reveal abuse committed against a child. In either of these cases, we must report it to the appropriate authorities.

By signing this assent form, you are letting us know that you have read the form and have asked any questions you have about the project, and you assent to participate in the Shout Listening Project Youth Listening Circle.

If you have any questions about the project please contact Josh Diamond at diamonjn@jmu.edu or 540-830-2721

Name of participant *

City participant lives in *

State participant lives in *

Tennessee

Virginia

Age of participant *

What Listening Circle is the participant attending? *

I have read this form, I had an opportunity to ask any questions I have about the Listening Project, and I agree that I will participate in an Appalachian shOUT Listening Circle. *

I agree (this constitutes your signature)

Date *

YYYY

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