!

Revised Date 10/24/2013

Consent to Participate in Research
Information to Consider About this Research

The Institutional Review Board (IRB) at Western State Colorado University has reviewed and
approvedthis research project [HRC2017-01-01R47].

Finding Effective Responses to Student Suicides in Public High Schools

Principal Investigator: Matt Smith
Department: Western State Colorado University Teacher Education Program
Contact Information:
Gunnison High School
Matt Smith
800 W. Ohio Ave.
Gunnison, CO. 81230
970.641.7700 (x3626)

Faculty Advisor:
Kim Silbaugh
Lecturer, Department of Education
Western State Colorado University
970-943-2148
ksilbaugh@western.edu

What is the purpose of this research?

Your student has been invited to participate in a research study about the Sources of
Strength program. By conducting this study, we hope to learn about students
perceptions of how Gunnison High School is responding to their social and emotional
needs.

Why am I being invited to take part in this research? [OPTIONAL] Are there
reasons I should not take part in this research?

Your student is being invited to participate in this research project because they are a
high school student involved in the Sources of Strength program. The research project
is open to all students involved in the Sources of Strength program. I am looking to
recruit approximately 15 to 20 high school students in the Sources of Strength program
for this research project.

What will I be asked to do?

 !
Revised Date 10/24/2013
The research procedures will be conducted at a Sources of Strength meetings in early
February and mid-April. If you agree to your student being part of the research, they will
be asked to complete an anonymous survey, asking them questions about their opinion
of Gunnison High Schools response to their social/emotional needs. The total amount
of time needed to complete each survey is approximately 15 minutes.

What are possible harms or discomforts that I might experience during the
research?

To my knowledge, the risk of harm and discomfort from participating in this research is
no more than your student would experience in every day life. The survey is completely
anonymous and steps have been taken to assure complete anonymity of your student.
It is unlikely that some of the questions in the survey may be upsetting or stressful. If so,
we can tell your student about some people who may be able to help them with these
feelings.

What are possible benefits of this research?

By participating in the survey, your student may benefit by their school having more
information about ways to meet their social and emotional needs. They may also benefit
by playing an active role in shaping the future strategies of Gunnison High School. The
information from this research project may also benefit future students at Gunnison High
School.

Will I be paid for taking part in the research?

Your student will not be paid for the time they volunteer while being in this study. They will also
not receive any extra credit or other academic benefits by volunteering for this research project.

What will it cost me to take part in this research?

There will be no cost for your student to be part of this research.

How will you keep my private information confidential?

This study is anonymous. That means that no one, not even members of the research team,
will know that the information you gave came from you.

Whom can I contact if I have a question?

The people conducting this study will be available to answer any questions concerning this
research, now or in the future. You may contact the Principal Investigator at 970.641.7700
(x3626). If you have questions about your students rights as someone taking part in research,
contact the Western State Colorado Universitys Human Research Committee Chair, Lance
Dalleck, through email at ldalleck@western.edu.
 !
Revised Date 10/24/2013

Do I have to participate?

Your students participation in this research is completely voluntary. If they do decide to take
part in the study, you and/or your student can still decide at any time that you no longer want to
participate. There will not be any penalties or consequences should you and/or your student not
participate in the study.

This research project has been approved on _____(date) by the Institutional Review Board
(IRB) at Western State Colorado University. This approval will expire on [Expiration Date]
unless the IRB renews the approval of this research.

I have decided I want to take part in this research. What should I do now?

If you have read this form, had the opportunity to ask questions about the research and received
satisfactory answers, and want to participate, then sign the consent form and keep a copy for
your records.

Participants Parent/Guardian Name (PRINT) Signature Date

Participant's Name (PRINT) Signature Date

 !

Revised Date 10/24/2013

Consentimiento para participar en la investigacin

Informacin a considerar sobre esta investigacin

La Junta de Revisin Institucional (IRB) en la Universidad de Colorado del estado

occidental ha revisado y aprobado este proyecto de investigacin
[HRC2017-01-01R47].

Encontrar respuestas eficaces a suicidios de estudiantes en escuelas pblicas

secundarias

Investigador principal: Matt Smith

Departamento: Programa de Educacin de Maestros de Western Colorado State
University
Informacin de contacto:
Gunnison High School
Matt Smith
800 W. Ohio Ave.
Gunnison, CO 81230
970.641.7700 (x3626)

Asesor de la Facultad:
Kim Silbaugh
Profesor, Departamento de Educacin
Western Colorado State University
970-943-2148
ksilbaugh@Western.edu

Cul es el propsito de esta investigacin?

Su estudiante ha sido invitado a participar en un estudio de investigacin sobre el

programa de, Sources of Strength. Mediante la realizacin de este estudio,
pretendemos conocer las percepciones de los estudiantes de cmo Gunnison High
School responde a las necesidades sociales y emocionales.

Por qu estoy siendo invitada a participar en esta investigacin?

[OPCIONAL] Hay razones que no debo tomar parte en esta investigacin?

Su hijo est invitado a participar en este proyecto de investigacin porque es un

estudiante de una secundaria que participa en el programa de Sources of Strength. El
proyecto de investigacin est abierto a todos los estudiantes involucrados en el
programa Sources of Strength. Estoy buscando aproximadamente 15 a 20
 !

Revised Date 10/24/2013

estudiantes en el programa de Sources of Strength para este proyecto de
investigacin.

Qu pedirn hacer?

Los procedimientos de investigacin se realizar en las reuniones de una fuentes de la

fuerza a principios de febrero y mediados de abril. Si est de acuerdo a su estudiante
ser parte de la investigacin, se les pedir completar una encuesta annima,
hacindoles preguntas acerca de su opinin de Gunnison secundaria de respuesta a
las necesidades social/emocional. La cantidad total de tiempo necesario para completar
cada encuesta es de aproximadamente 15 minutos.

Cules son los daos o molestias posibles que podra pasar durante la
investigacin?

Que yo sepa, el riesgo de dao y las molestias de participar en esta investigacin no es

ms que su estudiante experimentara en la vida cotidiana. La encuesta es
completamente annima y medidas se han adoptado para asegurar el anonimato
completo del estudiante. No es probable que algunas de las preguntas en la encuesta
pueden ser inquietante o estresante. Si es as, podemos decir a su estudiante sobre
algunas personas que pueden ayudarles con estos sentimientos.

Cules son los posibles beneficios de esta investigacin?

Al participar en la encuesta, puede beneficiar a su alumno por su escuela tener ms

informacin sobre maneras para satisfacer sus necesidades sociales y
emocionales. Tambin pueden beneficiarse por desempear un papel activo en la
conformacin de las estrategias futuras de Gunnison High School. La informacin de
este proyecto de investigacin tambin puede beneficiar a futuros estudiantes en
Gunnison High School.

Me pagarn por participar en la investigacin?

El estudiante no se pagar por el tiempo que voluntarios mientras que en este estudio. Tambin
no reciban ningn crdito adicional u otros beneficios acadmicos como voluntario para este
proyecto de investigacin.

Qu costar para tomar parte en esta investigacin?

No ser costo para el estudiante ser parte de esta investigacin.

Cmo se mantendr mi informacin privada confidencial?

Este estudio es annimo. Eso significa que nadie, ni incluso los miembros del equipo de
investigacin, se sabe que la informacin que dio, vino de usted.
 !

Revised Date 10/24/2013

Quin puedo contactar si tengo una pregunta?

Las personas llevando a cabo este estudio estar disponibles para responder cualquier
pregunta sobre esta investigacin, ahora o en el futuro. Ponerse en contacto con el
Investigador Principal en a 970.641.7700 (x3626). Si usted tiene preguntas sobre los derechos
de sus alumnos como alguien participar en la investigacin, pngase en contacto con
Presidente del Comit de investigacin humana de Universidad de Colorado del estado de
Western, Lance Dalleck, a travs de correo electrnico a ldalleck@western.edu.

Tengo que participar?

Participacin de los estudiantes en esta investigacin es completamente voluntaria. Si deciden

participar en el estudio, usted o su estudiante puede todava decidir en cualquier momento que
usted ya no quiere participar. No habr las sanciones o consecuencias en caso de que su
estudiante no participar en el estudio.

Este proyecto de investigacin ha sido aprobado en ___(date) por la Junta de revisin

institucional (IRB) en Western State Colorado University. Esta autorizacin vencer
[vencimiento] a menos que la IRB renueva la aprobacin de la presente investigacin.

He decidido que quiero participar en esta investigacin. Qu debo hacer ahora?

Si usted ha ledo este formulario, tuvieron la oportunidad de hacer preguntas sobre la
investigacin y recibido respuestas satisfactorias y desea participar, entonces firmar el
formulario de consentimiento y conserve una copia para sus registros.

Padres nombre (IMPRIMA) firma fecha del participante

Fecha de firma del participante (nombre)

 !
Revision Date: 10/23/2013
Assent for Minors Under 18

The Institutional Review Board (IRB) at Western State Colorado University has reviewed and ap-
proved this research project [HRC2017-01-01R47].

What is research?
We are asking you to be in a research study. Research is a way to test new ideas. Research helps us learn new
things. Being in research is your choice. You can say Yes or No. Whatever you decide is OK.

Why are we doing this research?

In our research study we want to see how students feel about their schools social environment.

What will happen in the research?

I am asking your permission to record data for this research through the use of a survey.

What are the good things that can happen from this research?
What we learn in this research may or may not help you now. When we finish the research we hope we know
more about how you feel about the Sources of Strength program and how Gunnison High School might better
respond to your social/emotional needs.

What are the bad things that can happen from this research?
If ever you feel uncomfortable answering the questions, you can pass and not answer. It is ok if you choose to
do this.

What else should you know about the research?

Being in the research is your choice. You can say Yes or No. Either way is OK.
If you say Yes and change your mind later that is OK. You can stop being in the research at any time. If you
want to stop, please tell me or Mrs. Macort.

Take the time you need to make your choice. Ask us any questions you have. You can ask questions any time.

Matt Smith
Name and Signature of Researcher Obtaining Assent Date

Participants Statement
The researcher has told me about the research study. I had a chance to ask questions. I know I can ask
questions or stop at any time. I want to be in the research study.

Name of Research Participant

Signature of Research Participant Date

Signature of Parent/Legal Guardian of Minor (Research Participant) Date

Researchers name and contact information:

Matt Smith
Gunnison High School
800 W. Ohio Ave.
Gunnison, CO. 81230
970.641.7700 (x3626)
matt.smith@gunnisonschools.net

Copies to: Research Participant and Parent/Legal Guardian

 !
Fecha de revisin: 23/10/2013

Consentimiento para menores de edad menores de 18 aos

La Junta de Revisin Institucional (IRB) en la Universidad de Colorado del estado occidental ha

revisado y aprobado este proyecto de investigacin [HRC2017-01-01R47].

Qu es investigacin?
Le pedimos estar en un estudio de investigacin. La investigacin es una manera de probar nuevas
ideas. Investigacin nos ayuda a aprender cosas nuevas. Estar en la investigacin es su opcin. Se puede decir
s o no. Lo que decida est bien.

Por qu estamos haciendo esta investigacin?

En nuestro estudio de investigacin queremos ver...

Qu pasar en la investigacin?
Pido su permiso para grabar los datos para esta investigacin a travs de una encuesta.

Cules son las cosas buenas que pueden pasar de esta investigacin?
Lo que aprendemos en esta investigacin pueden o no pueden ayudar ahora. Cuando terminamos la
investigacin esperamos que sabemos ms sobre cmo te sientes sobre el programa, Sources of
Strength y cmo Gunnison secundaria podra responder mejor a las necesidades social/emocional.

Cules son las cosas malas que pueden suceder de esta investigacin?
Si alguna vez te sientes incmoda contestando a las preguntas, puede pasar y no responder. Es
aceptable si usted elige hacer esto.

Qu ms debera saber acerca de la investigacin?

Estar en la investigacin es su opcin. Se puede decir s o no. De cualquier manera est bien.
Si dice que s y cambia de opinin despus est bien. Usted puede dejar de ser en la investigacin
en cualquier momento. Si usted quiere parar, por favor diga me o Sra. Macort.

Tomar el tiempo que necesita para hacer su eleccin. Pregntenos cualquier duda que tenga. Puede
hacer preguntas en cualquier momento.

Matt Smith
__________________________________________________________________________________________
Nombre y firma del investigador obtener dictamen fecha

Declaracin del participante

El investigador me ha dicho sobre el estudio de investigacin. Tuve la oportunidad de hacer
preguntas. S que puedo hacer preguntas o detener en cualquier momento. Quiero estar en el
estudio de investigacin.

__________________________________________________________________________
Nombre del participante de la investigacin

______________________________________________________________________________________
Firma del participante Fecha de investigacin

_______________________________________________________________________________________
Firma del padre o Tutor Legal del menor (investigacin participante) fecha

El nombre del investigador e informacin de contacto:

Matt Smith
High School secundaria de Gunnison
800 W. Ohio Ave.
Gunnison, co 81230
970.641.7700 (x3626)
Matt.Smith@gunnisonschools.net

Copias para: investigacin participante y padre o Tutor Legal

 Sources of Strength Survey

Directions: Please read the following statements and score each statement according to the
scale below. Should at any time you feel uncomfortable answering any of these questions, feel
free to skip the question.

1 - Strongly Disagree 2 - Disagree 3 - Not Sure 4 - Agree 5 - Strongly Agree

Adults at Gunnison High School are 1 2 3 4 5

willing to help students with their social/
emotional needs:
Students at Gunnison High School are 1 2 3 4 5
willing to help their peers with
challenging thoughts and emotions.
Sources of Strength has created a 1 2 3 4 5
network of support for students at
Gunnison High School that may be
dealing with challenging thoughts/
emotions.
I would tell an adult about a suicidal 1 2 3 4 5
friend, even if that friend asked me to
keep it a secret.

I know one adult on the Gunnison High 1 2 3 4 5

School campus that I could approach
with my social/emotional problems.
I know at least one student on the 1 2 3 4 5
Gunnison High School campus that I
feel comfortable sharing my problems
with
The Sources of Strength program is 1 2 3 4 5
creating better connections between
students and their peers.
If I was really upset and needed help, 1 2 3 4 5
my friends would want me to talk to an
adult.

I feel a general sense of support for my 1 2 3 4 5

social/emotional needs at Gunnison
High School.
I feel comfortable reaching out to other 1 2 3 4 5
students when I am dealing with
challenging emotions.
The Sources of Strength program is 1 2 3 4 5
creating better relationships between
students and adults on the Gunnison
High School campus.
I have told a friend who was dealing 1 2 3 4 5
with challenging thoughts and emotions
to speak with an adult
When I am facing challenging thoughts/ 1 2 3 4 5
emotions, I would be more likely to
seek help from someone outside the
school community

Sources of Strength has made a 1 2 3 4 5

positive impact at Gunnison High
School.
I feel like Sources of Strength has 1 2 3 4 5
provided me with the support that I
need to handle challenging thoughts
and emotions.
 How does it feel to be a Gunnison Cowboy?

We want to know:

Do you feel supported by your peers?

Do you feel supported by your teachers?
Does GHS have a friendly environment?

_________________________________________________

What?
A brief survey about your schools social environment.

When?
Next Sources of Strength Meeting

Who?
All students willing to participate (with consent).

____________________________________________________________________________

For more information, contact Mr. Matt Smith at

matt.smith@gunnisonschools.net

The Institutional Review Board (IRB) at Western State Colorado University has
reviewed and approved this research project [HRC2017-01-01R47].
 Cmo se siente ser un Cowboy de Gunnison?

Queremos saber:

Te sientes apoyado por tus compaeros?

Te sientes apoyado por tus maestros?
Tiene el GHS un ambiente amigable?

_________________________________________________

Qu?
Una breve encuesta Sobre tu escuela.

Cuando?
Siguiente Reunin de Fuentes de Fuerza.

Quien?
Todos los estudiantes estn dispuestos a
participar (con consentimiento).

_________________________________________________

Para ms informacin, contacte al Sr. Matt Smith en

matt.smith@gunnisonschools.net

El Consejo de Revisin Institucional (IRB) en la Universidad Estatal de Colorado del

Oeste ha revisado y aprobado este proyecto de investigacin [HRC2017-01-01R47].