0 Appendix F4

OMB Control No:
Expiration Date:

5TH GRADE FOLLOW-UP OF THE EARLY HEAD START STUDY
CHILD ASSENT FORM
WHAT IS THE STUDY ABOUT?

You are asked to be in Early Head Start 5th Grade Follow-up Study because we are trying to
learn more about how children your age and their parents are doing. The study might find out
things that will help children like you with growing up and parents with raising children. We are
inviting you to be in the study because you have been part of another research study called the
Early Head Start Study before. We explained the study to your parent and your parent said that
we could ask you if you want to be in it.
IF YOU DECIDE TO BE IN THE STUDY WHAT WILL HAPPEN?

If you decide to be in this study, we will ask you some questions about yourself. We will also do
some activities with you to see how you are growing up. It will take about 30 minutes for you to
complete the interview and the activities. We will also ask you to do an activity together with
your parent to see how the two of you work on a task. We will film this activity on a video
camera. The filming will take about 15 minutes. Your teacher will also be asked some questions
about how you are doing in school.
DO YOU HAVE TO BE IN THE STUDY?

You do not have to be in the study. No one will be upset if you don’t want to do this study. If
you don’t want to be in this study, you just have to tell us. It's up to you. You can also take
more time to think about being in the study.
WHO WILL SEE THE INFORMATION ABOUT YOU?

The information collected about you during this study will be kept safely locked up. Nobody will
be able to know or look at it except the people doing the research. So, what you tell us will not
be given to your parents or your teachers.
.
WILL ANY PART OF THE STUDY MAKE ME FEEL UNCOMFORTABLE?

It is possible that some of the questions or activities may make you feel bad. You can let us
know this, and it is ok to stop answering the questions or doing the activity at any time.

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

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WILL YOU BE COMPENSATED FOR PARTICIPATING IN THE STUDY?
You will receive $10 for participating in the study.
WHAT IF YOU HAVE QUESTIONS ABOUT THE STUDY?

You can ask any questions that you have about the study. If you have a question later that you
didn’t think of now, you can call [insert study telephone number]
If you agree to participate, please sign this form.

Name of Child (Printed)

Signature of Child

Date

Name of Parent (Printed)

Signature of Parent

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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