0 Permission to Contact Teacher

OMB Control No:
Expiration Date:

5TH GRADE FOLLOW-UP OF THE EARLY HEAD START STUDY
PERMISSION TO CONTACT TEACHER CONSENT FORM
My child and I have voluntarily agreed to be in a research study that wants to learn how
parents and children who participated in the Early Head Start Study are doing now that the
children are in fifth grade or in their sixth year of their formal education. The study also wants
to learn from the child’s teacher how the child is doing in school.
The study is conducted by a research team from and
Mathematica Policy Research, Inc. in Princeton NJ for the U.S. Department of Health and
Human Services. About 2,700 children and their parents all over the country have been asked
to participate in the study.
I have agreed for the study team to collect information on how my child is doing in school.
Therefore, I give the research team permission to contact my child’s teacher to answer
questions about how my child is doing in school, including questions about attendance and test
scores.
I understand that the information my child’s teacher will give to the research team will be kept
strictly confidential and will not be shared with me, my child or anybody else.
I also give permission for my child’s teacher to call at
xxxxx or Mathematica Policy Research at xxxxx if my child’s teacher has any questions about
the study or my being in the study.
Please sign this form if you agree to allow the research team to contact the child’s teacher.

__________________________________________

__________________

Print Parent’s Name

Date

_________________________________________
Print Child’s Name

___________________
Date

______________________________________________ _____________________
Name of Person Administering this Form
Date

_________________________________________ ____________________
Signature of Person Administering this Form
Date

Prepared by Mathematica Policy Research, Inc.
(7-1-06)

Page 1