0 Appendix F1

OMB Control No:
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5TH GRADE FOLLOW-UP OF THE EARLY HEAD START STUDY
PARENT CONSENT FORM
WHAT THE STUDY IS ABOUT
The 5th Grade Follow-up Study wants to learn how parents and children who earlier participated in the Early
Head Start Study are doing now that the children are in fifth grade or in the sixth year of their formal
education. You and your child are invited to be part of this study because your child was a participant in the
Early Head Start Study.
The 5th Grade Follow-up 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 are asked to be in the study.
WHAT IS EXPECTED OF YOU IF YOU DECIDE TO PARTICIPATE
If you decide to participate in this study, a member of the research team will ask you some questions about
yourself, how things have gone for you, and about your relationship with your child. The interview will take
about 55 minutes to complete.
If you agree for your child to be in the study, your child will also be asked to sign an agreement to
participate. You will be asked to sign this agreement as well. We will ask your child questions about him or
herself. We will also do some activities with your child to see how he or she is growing up. For your child to
complete the interview and the activities it will take about 85 minutes.
In addition, we will ask you and your child to do an activity together to see how the two of you work on a
task. To do this activity it will take about 15 minutes. We will ask you to sign a separate permission form to
videotape this activity.
All interviews and activities will be done in your child’s home.
As part of the study, we will ask your permission to contact one of the child’s teachers. If the teacher
agrees to participate in the study, this person will be asked to provide information about him or herself and
asked questions about how your child is doing in school, including questions about attendance and test
scores. We will ask you to sign a separate permission form for us to contact the child’s teacher.
THE INFORMATION YOU PROVIDE WILL BE KEPT CONFIDENTIAL
Everything you tell the research team will be kept strictly confidential and will not be shared with anybody
else. The research team will not share any information you share with us with your child’s teacher, and we
will not share with you the information that the teacher will give us. Only the research team will be able to
see the information you give them and nothing will ever be said about you or your child as individuals.
Information about you will be combined with information about everybody else in the study, so the
researchers can say things like “half of the families in the study have more than one child.” However, if a
member of the research team observes child abuse, it must be reported as required by law.

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

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YOUR PARTICIPATION IN THE STUDY IS VOLUNTARY
Your participation in the study is completely voluntary. You and your child only have to participate in the
study if you want to. If you decide to be in the study, you can withdraw at any time.
RISKS AND BENEFITS OF PARTICIPATING IN THE STUDY?
There are no known risks of participating in this study except for the potential discomfort of answering
sensitive questions or participating in activities. Your participation in the study may provide information that
could help other children and their families in the future.
YOU WILL BE COMPENSATED FOR PARTICIPATING IN THE STUDY
You will receive $30 for participating in the study. Your child will also receive $10 for participating in the
activities.
IF YOU HAVE QUESTIONS ABOUT THE STUDY
If you have questions about the study or your rights as a research volunteer, you can call toll-free at xxxxx.
If you agree to participate, please sign this form.

Name of Participant (Printed)

Signature of Participant

Date

Name of Person Administering this Form (Printed)

Signature of Person Administering this Form

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

Date

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