Questions marked with a * are required Exit Survey
Information and Consent Form
(Permission Slip)
Title: Opportunity Youth Needs Assessment
Investigator: Stacy M. Deck, PhD, MSSW
Hello! The Coalition Supporting Young Adults would like to invite you to participate in a survey. This research is being supervised by Dr. Stacy Deck, a social work professor at Spalding University. We want to learn more about the needs of youths and young adults in this community.
To be eligible to participate, you must be between the ages of 16 and 24, and currently living in Jefferson County. You also must have experienced at least one of the following within the last two years: (a) simultaneously being unemployed and not in school, (b) being homeless, (c) being in foster care, (d) being involved in the juvenile justice system, (e) having 6+ unexcused absences or tardies in one school year during high school, and/or (f) being suspended 2+ times in one school year during high school.
1. Purpose: We want to help the Coalition Supporting Young Adults and their partners find out what education, employment, health, shelter and food resources are needed in the Louisville community for youth and young adults.
2. Description: The survey will ask 20 questions about resources you may need. We will also ask for a little information about you (like your age, race, etc.), but you will not have to give your name or any information that could link your answers to you. You can also skip any questions you dont want to answer. It will take about 15 minutes.
3. Risks: We are not aware of any serious risks of participating in this project. As you think about your needs, you might feel frustrated if you have many unmet needs. If you need immediate help or information, you can call the Crisis and Information Line at (502) 589-4313 or (800) 221-0446. This resource is available 24/7. If you want someone from YMCA Safe Place to call you later to discuss resources, you can let us know.
4. Benefits: By participating, you will be providing information concerning resources and services that you believe are needed and difficult to access. This may or may not directly help you, but it should be of benefit to others like you in the future. In appreciation for your time, you will be offered an opportunity to enter a drawing for a $50 gift card at the end of the survey.
5. Your rights: You do not have to participate. You can quit if you want to. You can skip a question if you want to. Whatever you decide to do is up to you. Your decisions about the survey will not affect the services you receive.
6. Confidentiality: We will keep your answers to these questions confidential. We will give CSYA a summary of the results for the group, but we will not say what any individual person told us. We will not use your name or any other information that would identify you.
7. Contact information: If you have any questions, you can contact Dr. Stacy Deck (502-873-4477) or sdeck@spalding.edu. If you are concerned about your rights as a research volunteer and you want to talk to someone different, you can call Dr. Kevin Borders (502-873-4482). He is the Chair of the Spalding University School of Social Work.
8. Thank you: We appreciate your considering our request to participate. Please complete the survey only once. You can let us know your decision below. Please pick one response.
I am at least 18 years old, I have read the above information, and I agree to participate under the conditions outlined above.
I am under age 18, but I would still like to participate in this needs assessment.
I do not wish to participate.
If you or someone you know needs immediate help or information, you can call the Crisis and Information Line at 502- 589-4313 or 800-221-0446.  This resource is available 24/7. 
Respondent Anonymity Assurance