Appendix E - Consent and Assent forms

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National Survey of Child and Adolescent Well-Being Second Cohort (NSCAW II)

Appendix E - Consent and Assent forms

OMB: 0970-0202

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0202 can be found here:

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Consent and Assent Forms

Caseworker Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The Administration for Children and Families of the U.S. Department of Health and Human Services is funding a national longitudinal survey of children and families in the child welfare system. RTI International (RTI), a not-for-profit research organization in North Carolina, and staff at ICF Caliber, Walter R. McDonald & Associates, Inc (WRMA), Tufts-New England Medical Center, the Child and Adolescent Services Research Center, and the University of Illinois at Urbana-Champaign are conducting this survey.

SELECTION OF PARTICIPANTS

RTI representatives are contacting families of children randomly selected in 2008 and 2009 from child welfare agencies throughout the United States. There are over 5,300 children and families participating in this study. You have been identified as the primary caseworker or service provider for one of the participating children. We are following up with the sampled children and their current caregivers approximately 18 months after the close of the index investigation.

CASEWORKER INTERVIEWS

The caseworker interview collects information about the child’s history in the child welfare system and services recommended or provided by the agency. Your answers combined with the answers of others in the study will help us describe the needs of children and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

VOLUNTARY PARTICIPATION

Your participation in this study is completely voluntary. You can refuse to answer any and all questions. Your decision about participation will not affect you, your job, or any services that the child may be receiving. You have the right to stop the interview at any time.

RISKS

There are no physical risks to you from participating in this interview. It is possible that some questions might make you uncomfortable or feel various emotions, such as sadness.

BENEFITS

There are no direct benefits to you, to the caregiver, or to the child from answering our questions. However, you will be helping us learn more about the needs of children and the services available to them.

CONFIDENTIALITY

Your answers will be entered into a computer and labeled with a case identification number. Your name and that of the child will not be reported with any information you provide. Information you provide will be combined with answers of thousands of others and reported in a summary form. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protection at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

The Federal Government has issued a Certificate of Confidentiality (authorized by the Public Health Service Act Section 301(d), 42 U.S.C Section 241 (d), 1988) to the researchers who are conducting this study which authorizes us to protect the privacy of individuals who participate.

The above information has been explained to me, and my signature below indicates that I give consent for my interview.

We are using a laptop quality control (QC) system for this study. The system runs on the computer and may record what you and I say to each other during parts of the interview. Neither you nor I will know when the computer is recording our conversation. The recording will be reviewed by project staff at RTI to monitor my work. The recordings will only be used for those purposes and will be kept confidential. The files will be destroyed after they have been used to review my work. Those project staff who listen to the recording will know who I am, but will not know who you are. Is it all right with you if this QC system runs during this interview?

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Caseworker	Fill in CW Respondent 8-digit ID #	Printed Name of Youth

Signature of Caseworker	Signature of Interviewer	Date

Caregiver Permission Form for Combining NSCAW Data with Other Research Data

Why should I grant permission for my NSCAW data to be combined with other data?

All of the information we have collected from or about you and your child during the NSCAW interviews can be even more valuable to researchers if it can be combined with other information on you and your child that we obtain from sources outside this survey— information that exists now, as well as information in the future. We are requesting your permission to add other sources of information to you and your child’s interview data.

There are two types of data that could be linked to your interview data once it gets back to RTI International. First, we would link you and your child’s interview data to records collected from participating child welfare services agencies. Adding this information will help us to learn more about any foster care, adoption, or other services that you and your child receive. Second, at some point in the future, researchers interested in the NSCAW data may wish to add other information, such as data on state child welfare policies, to you and your child’s interview data. Your permission would allow these researchers to combine this new information to you and your child’s interview data. However, your permission for combining your child’s information only applies until the time your child becomes an adult (usually at age 18). At that time, we will not combine your child’s information until we have your child’s direct approval to do that.

How will the data be combined and who will it be released to?

The information we obtain from these sources will be combined with the information you give us in the interviews and made available to researchers on a very restricted basis. No personally identifying information about you or your child will be included. Before receiving data, researchers must complete an application that gives good reason for their use of the information. Applications will be reviewed and either approved or denied by a group of individuals whose job it is to protect the rights of people like you who participate in research studies. The information will only be used for reports. Your name and your child’s name will not appear in any of these reports.

What are the risks and benefits associated with granting permission for this request?

The only risk you are taking by allowing your NSCAW data to be combined with other information is the small risk that some people who do research and get your information might not follow the rules we set for using your information. There are also no direct benefits for allowing your or your child’s NSCAW information to be combined with other types of information. Your decision with regard to this request will not affect any services you or your child may be receiving now or in the future. By answering “yes”, you are giving permission for all of your and your child’s NSCAW information we have ever collected in our interviews to be used in the future for other important research studies that may be approved.

What are my rights with regard to this request?

You have the right to refuse this request. However, we hope you will give us your permission to use your and your child’s data in this way. If in the future should you decide that you no longer want your or your child’s information combined with other records, you should contact Pat Crowley at RTI International (toll-free at 877-254-1953, extension 67) to record your request.

Check one box.

	Yes, I consent to having all of my family’s NSCAW information ever collected in interviews to be added in the future to information in other important research studies. This permission will take effect when RTI releases information from this round to researchers.

	No, I do not want any of my NSCAW information ever collected in interviews to be added to other information. This refusal request will take effect when RTI releases information from this round to researchers.


Printed Name of Child	Printed Name of Current Caregiver	Fill in CCG Respondent 8-digit ID #

Fill in Child Respondent 8-digit ID	Signature of Current Caregiver	Date

Authorization for Teacher to Release Information

Teacher Authorization Form

National Teacher Survey of Children and Adolescents

Name of Child:______________________________________ Case ID#: 

Fill in Child Respondent 8-digit ID #

By signing this form, I give permission to RTI International (RTI) to contact my child’s primary teacher, language arts teacher, special education teacher, or other classroom instructor who has taught my child for at least two months within the current or last school year. I understand that information regarding my child’s behavior during class time, interactions with classmates, teachers, and peers, and involvement in school-related activities such as sports and clubs will be collected. I further understand that school performance and attendance information will also be obtained.

The purpose or need for such disclosure is to obtain information for a research study my child and I are participating in to learn more about the behavior, learning, development, and needs of children up to 18 years of age. The study is being funded by the U.S. Department of Health and Human Services (DHHS) and is being conducted by RTI.

I understand that this information will be kept strictly confidential. Any information released because I have signed this consent will be seen only by research personnel and will be used only for research purposes. This information will not be given to anyone else and will not be used in any way other than that explained in this form without my specific written permission. The time period covered by this authorization is one year, ending on ___________________________________.

Print Date One Year From Today Above

______________________________________________________________________________________________

The above information has been explained to me and I give permission to my child’s teacher to release information to the researchers involved in this study.

PLEASE PRINT CLEARLY

Parent/Guardian’s Name: ________________________________________________________

FIRST LAST

Name of Child’s Teacher (if known):

Mr/Ms __________________________________________________

FIRST LAST

Name of Principal (if known): Mr/Ms __________________________________________________

FIRST LAST

Name of School (if known): ________________________________________________________

Address of School (if known):

________________________________________________________

NUMBER AND STREET

________________________________________________________

CITY STATE ZIP

School Phone Number (if known): ( )___________________________________________________

___________________________________ ______________________

Signature of Parent (if applicable) Date

__________________________________________ ______________________

Signature of Legal Guardian Date

Disposition: Original and copy to RTI; copy to respondent Version 2 May 2009

Caregiver Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The Administration for Children and Families of the U.S. Department of Health and Human Services is funding a national longitudinal survey of children and families in contact with the child welfare system. RTI International (RTI), a not-for-profit research organization in North Carolina, and staff at ICF Caliber, Walter R. McDonald & Associates, Inc (WRMA), Tufts-New England Medical Center, the Child and Adolescent Services Research Center, and the University of Illinois at Urbana-Champaign are conducting this survey.

SELECTION OF CHILDREN

RTI representatives are contacting families of children selected in 2008-2009 from child welfare agencies throughout the United States. Your child is among over 5,300 children selected to be interviewed. We are following up with sampled children and their caregivers approximately 12-14 months after the initial interview. We must have permission from a parent or legal guardian before we observe or talk with the child. At that point, your child may choose whether or not to participate in the study.

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview you about your child and your family. Your answers combined with the answers of other caregivers in the study will help us describe the needs of children and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

TYPES OF QUESTIONS FOR PARENTS

The caregiver interview takes about 100 minutes, depending on the age of the child and other factors. The interviewer will ask questions about your child’s learning, behavior at home and at school, health, and relationships with friends. You will also be asked about services your child or family may receive, including your level of satisfaction with those services. In addition, we will ask questions about your attitudes about raising children, life experiences, family support, involvement with school and community activities, your interaction with your child, and things that may happen in your family like violence in the home, drug abuse, and other risky behaviors such as drinking, drug use, and involvement with the police.

TYPES OF QUESTIONS FOR CHILD

The interview with your child will last about 60-90 minutes, depending on the child's age and personal experiences. You will not know how your child answers the questions. Children will be observed to assess their language skills and how well they understand and perform certain tasks. Depending on their age, they will also be interviewed about their abilities, their experiences at home and at school, their feelings about family and friends, and their exposure to violence.

VOLUNTARY PARTICIPATION

Your participation in this study is completely voluntary. You can refuse to answer any and all questions. Your refusal would not affect any benefits that you or your child may be receiving. You have the right to stop the interview at any time. Your child’s participation in this study is also completely voluntary. He or she can refuse to answer any and all questions. His or her refusal would not affect any benefits or services that he/she may be receiving. Your child has the right to stop the interview at any time.

RISKS

There are no physical risks to you or your child from participating in this interview. It is possible that some questions might make you or your child uncomfortable or feel various emotions, such as sadness. If we learn during the course of these interviews that the life or health of the child is in danger, we will share that information with the appropriate county or state agency. More information is provided in the Confidentiality section below.

BENEFITS

There are no direct benefits to you or your child from answering our questions. However, you will be helping us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

To help us understand how the well-being of children changes over time, we or other researchers may contact you and your child in the future to update our information. Each of these additional interviews will also be completely voluntary.

CONFIDENTIALITY

Your answers will be entered into a computer and labeled with a case identification number. Your name and that of your child will not be reported with any information you provide. Information you provide will be combined with answers of thousands of others and reported in a summary form. To protect the privacy of both you and your child, neither of you will know the other’s interview answers. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two important exceptions. (1) If the interviewer or project staff think that your child’s life or health is in danger, they will inform the appropriate county or state agency. Also, if they think that your life or health is in serious danger, they will contact emergency assistance. (2) At some point in the future this research may be done by another organization. If that happens, with your consent, we would give contacting information for you and your child to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at the RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI 's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

Because your contribution is important, we will pay you $50 in cash for participating in the interview. We will also give your child a gift certificate for participating. The amount of the gift certificate is $20 for children age 11 or older and $10 for children age 10 or younger. If you participate in future rounds, you and your child will be paid for participating in the in-person interviews.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the parent interview is estimated to be 100 minutes. The time required to complete the child interview is also estimated to be 60-90 minutes, depending on the child’s age and personal experiences.

The above information has been explained to me, and my signature below indicates that I give consent for my interview.

I give consent for having contacting information for me and my child given to another research organization if they start doing this study.

Yes

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Caregiver Consent (short version)

National Survey of Child and Adolescent Well-Being (NSCAW)

TYPES OF QUESTIONS FOR PARENTS

The voluntary participation, risks, benefits, and confidentiality of this survey are the same as those described to you on the consent form you signed before your child’s interview. You will be given a copy of this consent form to keep.

Because your contribution is important, we will pay you $50 in cash for participating in the interview. If you participate in future rounds, you will be paid for participating in the in-person interviews.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the parent interview is estimated to be 100 minutes. The time required to complete the child interview is estimated to be 60-90 minutes, depending on the child’s age and personal experiences.

The above information has been explained to me, and my signature below indicates that I have completed a long-version consent for permission to approach my child for an interview and give consent for my interview.

I give consent for having contacting information for me and my child given to another research organization if they start doing this study.

Yes

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Caregiver Permission for Child Interview

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF CHILDREN

RTI representatives are contacting families of children selected from child welfare agencies throughout the United States. Your child is among over 5,300 children selected to be interviewed. We are following up with sampled children and their caregivers approximately 18 months after the initial interview. We must have permission from a parent or legal guardian before we observe or talk with the child. At that point, your child may choose whether or not to participate in the study.

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview your child about their experiences with the child welfare system, you, and your family. The child’s answers combined with the answers of other children in the study will help us describe the needs of children and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

TYPES OF QUESTIONS FOR CHILD

VOLUNTARY PARTICIPATION

Your child’s participation in this study is also completely voluntary. He or she can refuse to answer any and all questions. His or her refusal would not affect any benefits or services that he/she may be receiving. Your child has the right to stop the interview at any time.

RISKS

There are no physical risks to your child from participating in this interview. It is possible that some questions might make your child uncomfortable or feel various emotions, such as sadness. If we learn during the course of these interviews that the life or health of the child is in danger, we will share that information with the appropriate county or state agency. More information is provided in the Confidentiality section below.

BENEFITS

There are no direct benefits to your child from answering our questions. However, he or she will be helping us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

CONFIDENTIALITY

Your answers will be entered into a computer and labeled with a case identification number. Your name and that of your child will not be reported with any information your child provides. Information your child provides will be combined with answers of many others and reported in a summary form. To protect the privacy of both you and your child, neither of you will know the other’s interview answers. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two important exceptions. (1) If the interviewer or project staff feel that your child’s life or health is in danger, they will inform the appropriate county or state agency. Also, if they feel that your life or health is in serious danger, they will contact emergency assistance. (2) At some point in the future this research may be done by another organization. If that happens, with your consent, we would give contacting information for you and your child to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at the RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

Because your child’s contribution is important, we will give your child a gift certificate for participating. The amount of the gift certificate is $20 for children age 11 or older and $10 for children age 10 or younger. If your child participates in future rounds, he or she will be paid for participating in the in-person interviews.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the parent interview is estimated to be 100 minutes. The time required to complete the child interview is estimated to be 60-90 minutes, depending on the child’s age and personal experiences.

The above information has been explained to me, and my signature below indicates that I give my permission for my child to be approached for an interview.

I give consent for having contacting information for my child given to another research organization if they start doing this study.

Yes

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Caregiver Permission for Child Interview (short version)

National Survey of Child and Adolescent Well-Being (NSCAW)

TYPES OF QUESTIONS FOR CHILD

The voluntary participation, risks, benefits, and confidentiality of this survey are the same as those described to you on the consent form you signed before your interview.

Because your child’s contribution is important, we will give your child a gift card for participating. The amount of the gift card is $20 for children age 11 or older and $10 for children age 10 or younger. If your child participates in future rounds, he or she will be paid for participating in the in-person interviews.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the parent interview is estimated to be 100 minutes. The time required to complete the child interview is estimated to be 60-90 minutes, depending on the child’s age and personal experiences.

The above information has been explained to me, and my signature below indicates that I have completed my long-version consent form for my interview and that I give my permission for my child to be approached for an interview.

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.

You will be given a copy of this consent form to keep.


Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Second Parent/Guardian Permission for Child Interview

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF CHILDREN

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview your child about their experiences with you and your family. The child’s answers combined with the answers of other children in the study will help us describe the needs of children and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

TYPES OF QUESTIONS FOR CHILD

VOLUNTARY PARTICIPATION

RISKS

BENEFITS

There are no direct benefits to your child from answering our questions. However, he or she will be helping us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

CONFIDENTIALITY

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at the RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the parent interview is estimated to be 100 minutes. The time required to complete the child interview is estimated to be 60-90 minutes, depending on the child’s age and personal experiences.

The above information has been explained to me, and my signature below indicates that I give my permission for my child to be approached for an interview.

I give consent for having contacting information for my child given to another research organization if they start doing this study.

Yes

Check one box.

We are using a laptop quality control (QC) system for this study. The system runs on the computer and may record what your child and I say to each other during parts of the interview. Neither your child nor I will know when the computer is recording our conversation. The recording will be reviewed by project staff at RTI to monitor my work. The recordings will only be used for those purposes and will be kept confidential. The files will be destroyed after they have been used to review my work. Those project staff who listen to the recording will know who I am, but will not know who your child is. Is it all right with you if this QC system runs during this interview?

Check one box.

	Yes, I consent to having portions of my child’s interview recorded by the computer to test the quality control system.

	No, I do not want any portion of my child’s interview recorded.


Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Legal Guardian Permission for Minor Caregiver Interview

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF CHILDREN

RTI representatives are contacting families of children selected from child welfare agencies throughout the United States. There are over 5,300 children and families participating in this study. We are following up with sampled children and their caregivers approximately 12-14 months after the initial interview. Because a minor is the caregiver of the sampled child, we must have permission from a parent or legal guardian before we talk with the minor caregiver. At that point, the minor caregiver may choose whether or not to participate in the study, and whether or not the sampled child can also participate.

PURPOSE OF THIS NSCAW INTERVIEW

The data we obtain from the minor caregiver will be combined with the answers of other caregivers in the study to help us describe the needs of children and families and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

TYPES OF QUESTIONS FOR THE MINOR CAREGIVER

The interview with the minor caregiver will last about 100 minutes. The interviewer will ask the minor caregiver questions about the sampled child’s learning, behavior at home, health, and relationships with friends. The minor caregiver will also be asked about services the sampled child or the family may receive, including level of satisfaction with those services. In addition, we will ask questions about attitudes about raising children, life experiences, family support, involvement with school and community activities, the minor caregiver’s interactions with the sampled child, and things that may happen in the family like violence in the home, drug abuse, and other risky behaviors such as drinking, drug use, and involvement with the police. You will not know how the minor caregiver answers the questions.

VOLUNTARY PARTICIPATION

The minor caregiver’s participation in this study is completely voluntary. He or she can refuse to answer any and all questions. His or her decision about participation will not affect any benefits or services that he/she or the sampled child may be receiving. The minor caregiver has the right to stop the interview at any time.

RISKS

There are no physical risks to the minor caregiver from participating in this interview. It is possible that some questions might make the minor caregiver uncomfortable or feel various emotions, such as sadness. It is also possible that some of the minor caregiver’s answers to questions about violence or maltreatment will require that we share that information with the appropriate county or state agency. More information is provided in the Confidentiality section below.

BENEFITS

There are no direct benefits to the minor caregiver for answering our questions. However, the minor caregiver will be helping us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

To help us understand how the well-being of children changes over time, we or other researchers may contact the sampled child, minor caregiver, and his/her family in the future to update our information about the sampled child. Each of these additional interviews will be completely voluntary.

CONFIDENTIALITY

The minor caregiver’s answers and the information about the sampled child will be entered into a computer and labeled with a case identification number. The names of the minor caregiver and the sampled child will not be reported with any responses provided. Information we obtain will be combined with answers of many others and reported in a summary form. To protect the privacy of the minor caregiver and sampled child, you will not know either the minor caregiver’s or the sampled child’s answers. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two important exceptions. (1) If the interviewer or project staff feel that the sampled child’s life or health is in danger, they will inform the appropriate county or state agency. Also, if they think that the minor caregiver’s life or health is in serious danger, they will contact emergency assistance. (2) At some point in the future, this research may be done by another organization. If that happens, with your permission, we would give contacting information for the minor caregiver to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at the RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about the rights of the minor caregiver or sampled child as study participants, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this permission form to keep.

Because each respondent’s contribution is important, we will pay the minor caregiver $50 in cash for participating in the interview. We will also give the sampled child a gift certificate for participating. The amount of the gift certificate is $20 for children age 11 or older and $10 for children age 10 or younger.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the minor caregiver interview is estimated to be 100 minutes

The above information has been explained to me, and my signature below indicates that as legal guardian I give permission for the minor caregiver named below to be approached for an interview.

I give consent for having contacting information for the minor caregiver given to another research organization if they start doing this study.

Yes

Check one box.

We are using a laptop quality control system for this study. The system runs on the computer and may record what the minor caregiver and I say to each other during parts of their interviews. Neither the youth nor I will know when the computer is recording our conversation. The recording will be reviewed by project staff at RTI to monitor my work. The recordings will only be used for those purposes and will be kept confidential. The files will be destroyed after they have been used to review my work. Those project staff who listen to the recording will know who I am, but will not know who the minor caregiver is. Is it all right with you if this quality control system runs during this interview?

Check one box.

	Yes, I consent to having portions of the minor caregiver’s interview recorded by the computer.

	No, I do not want any portion of the minor caregiver’s interview recorded.


Printed Name of Legal Guardian	Fill in Minor Caregiver 8-digit ID #	Printed Name of Minor Caregiver

Signature of Legal Guardian	Signature of Interviewer	Date

Legal Guardian Permission for Child Interview

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF CHILDREN

RTI representatives are contacting families of children selected from child welfare agencies throughout the United States. We are following up with sampled children and their caregivers approximately 12-14 months after the initial interview. We must have permission from a parent or legal guardian before we observe or talk with the child. At that point, the child may choose whether or not to participate in the study. A child under your guardianship is among over 5,300 children selected to be interviewed.

PURPOSE OF THIS NSCAW INTERVIEW

The data we obtain from the child and about the child from his/her current caregiver, caseworker, and teacher will be combined with the answers of others in the study to help us describe the needs of children and families and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

TYPES OF QUESTIONS FOR CHILD

The interview with the child will last about 60-90 minutes, depending on the child's age and personal experiences. You will not know how the child answers the questions. Children will be observed to assess their language skills and how well they understand and perform certain tasks. Depending on their age, they will also be interviewed about their abilities, their experiences at home and at school, their feelings about family and friends, and their exposure to violence.

VOLUNTARY PARTICIPATION

The child’s participation in this study is completely voluntary. He or she can refuse to answer any and all questions. His or her decision about participation will not affect any benefits or services that he/she may be receiving. The child has the right to stop the interview at any time.

RISKS

There are no physical risks to the child from participating in this interview. It is possible that some questions might make the child uncomfortable or feel various emotions, such as sadness. It is also possible that some answers to questions will require that we share that information with the appropriate county or state agency. More information is provided in the Confidentiality section below.

BENEFITS

There are no direct benefits to the child from the child answering our questions. However, the child will be helping us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

To help us understand how the well-being of children changes over time, we or other researchers may contact the child and his/her family in the future to update our information. Each of these additional interviews will be completely voluntary.

CONFIDENTIALITY

The child’s answers will be entered into a computer and labeled with a case identification number. The name of the child and other respondents will not be reported with any responses provided. Information we obtain will be combined with answers of many others and reported in a summary form. To protect the privacy of the child, neither the child nor the caregiver will know the other’s interview answers. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two important exceptions. (1) If the interviewer or project staff feel that the child’s life or health is in danger, they will inform the appropriate county or state agency. (2) At some point in the future, this research may be done by another organization. If that happens, with your consent, we would give contacting information for the child to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at the RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

Because each respondent’s contribution is important, we will pay the current caregiver $50 in cash for participating in the interview. We will also give the child a gift card for participating. The amount of the gift card is $20 for children age 11 or older and $10 for children age 10 or younger.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the child interview is estimated to be 60-90 minutes, depending on the child’s age and personal experiences.

The above information has been explained to me, and my signature below indicates that as legal guardian I give permission for the child named below to be approached for an interview.

I give consent for having contacting information for the child given to another research organization if they start doing this study.

Yes

Check one box.

We are using a laptop quality control system for this study. The system runs on the computer and may record what the child and I say to each other during parts of the interview. Neither the child nor I will know when the computer is recording our conversation. The recording will be reviewed by project staff at RTI to monitor my work. The recordings will only be used for those purposes and will be kept confidential. The files will be destroyed after they have been used to review my work. Those project staff who listen to the recording will know who I am, but will not know who the child is. Is it all right with you if this quality control system runs during this interview?

Check one box.

	Yes, I consent to having portions of the child’s interview recorded by the computer.

	No, I do not want any portion of the child’s interview recorded.


Printed Name of Legal Guardian	Fill in Child Respondent 8-digit ID #	Printed Name of Child

Signature of Legal Guardian	Signature of Interviewer	Date

Legal Guardian Permission Form for Combining Child’s NSCAW Data with Other Research Data

Why should I grant permission for the child’s NSCAW data to be combined with other data?

All of the information we have collected from or about the child during the NSCAW interviews can be even more valuable to researchers when combined with other information on the child that we obtain from sources outside this survey— information that exists now, as well as information in the future.

We are requesting your permission to add other sources of information to your child’s interview data.

There are two types of data that could be linked to your child’s interview data once it gets back to RTI International. First, we would link your child’s interview data to records collected from participating child welfare services agencies. Adding this information will help us to learn more about any foster care, adoption, or other services that the child receives. Second, at some point in the future, researchers interested in the NSCAW data may wish to add other information, such as data on state child welfare policies, to your child’s interview data. Your permission would allow these researchers to combine this new information to your child’s interview data. However, your permission for combining your child’s information only applies until the time your child becomes an adult (usually at age 18). At that time, we will not combine your child’s information until we have your child’s direct approval to do that.

How will the data be combined and who will it be released to?

The information we obtain from these sources will be combined with the information the child and their caregiver give us in the interviews and made available to researchers on a very restricted basis. No personally identifying information about your child will be included. Before receiving data, researchers must complete an application that gives good reason for their use of the information. Applications will be reviewed and either approved or denied by a group of individuals whose job it is to protect the rights of people like you who participate in research studies. The information will only be used for reports. Your name and your child’s name will not appear in any of these reports. .

What are the risks and benefits associated with granting permission for this request?

The only risk you are taking by allowing the child’s NSCAW data to be combined with other information is the small risk that some people who do research and get your information might not follow the rules we set for using the child’s information. There are also no direct benefits for allowing the child’s NSCAW information to be combined with other types of information. Your decision with regard to this request will not affect any services the child or the caregiver may be receiving now or in the future. By answering “yes”, you are giving permission for all the child’s NSCAW information we have ever collected in our interviews to be used in the future for other important research studies that may be approved.

What are my rights with regard to this request?

You have the right to refuse this request. However, we hope you will give us your permission to use the child’s data in this way. If in the future should you decide that you no longer want the child’s information combined with other records, you should contact Pat Crowley at RTI International (toll-free at 877-254-1953, extension 67) to record your request.

Check one box.

	Yes, I consent to having all of the child’s NSCAW information ever collected in interviews to be added in the future to information in other important research studies. This permission will take effect when RTI releases information from this round to researchers.

	No, I do not want any of the child’s NSCAW information ever collected in interviews to be added to other information. This refusal request will take effect when RTI releases information from this round to researchers.


Printed Name of Child	Printed Name of Legal Guardian	Date

Fill in Child Respondent 8-digit ID	Signature of Legal Guardian

Agreement for Youth Aged 7 to 10

National Survey of Child and Adolescent Well-Being (NSCAW)

PRINTED NAME OF YOUTH:

PRINTED NAME OF PARENT/CAREGIVER:

My name is

I work for a company called RTI International (RTI). We are talking to some kids across the United States. The questions we will ask you are about the kinds of things you can do, how you behave at home and at school, how you feel about your family, your friends, and school, and about people who may help you. There are also some questions about things that may have happened in your home that scared or hurt you. You may also find that some of these questions bring back sad or frightening memories.

_______________________________ said it was okay for you to talk with me about these things. If it is okay with you, I would like to ask you some questions. Our talk today will last between one and two hours, depending on how much you have to say. We may contact you again in the future.

I am going to enter your answers into a computer I carry with me. Your answers will be labeled with a special number instead of your name so no one else will know these are your answers. No one will see your answers. There is one special case where I can’t promise not to tell anyone. If during our talk today I learn that your life or health is in danger, I will have to tell someone whose job it is to see that you are safe and protected.

If you don't want to talk to me, that is okay. If you don't want to answer a certain question, that is okay too. If you want to take a break at any time, just tell me.

You will be given a copy of this consent form to keep. When we finish I will give your parent/guardian a $10 gift card for you to say thanks for taking the time to talk with me.

May I ask you the questions?

	YOUTH AGREES -----> Would you like to sign your name on this form?

	YOUTH DOES NOT AGREE

	YOUTH DID NOT APPEAR TO UNDERSTAND EXPLANATION

The above information has been explained to me, and my signature below means that I agree to participate in this study.

We are using a recording system on the computer. The system may record what you and I say to each other during parts of the interview. Neither of us will know when the computer is recording what we say. The recording will be listened to by people at RTI to check on my work. The files will be destroyed after they have been used to review my work. The people who listen to the recording will know who I am, but will not know who you are. Is it all right with you if the recording system runs during this interview?

Check one box.

	Yes, I agree to having portions of this interview recorded by the computer.

	No, I do not want any portion of this interview recorded.


	Fill in Child Respondent 8-digit ID #

Signature of Youth	Signature of Interviewer	Date

Caregiver of Emancipated Youth Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The Administration on Children, Youth and Families of the U.S. Department of Health and Human Services is funding a national longitudinal survey of children and families in the child welfare system. RTI International (RTI),, a not-for-profit research organization in North Carolina, and staff at ICF Caliber, Walter R. McDonald & Associates, Inc (WRMA), Tufts-New England Medical Center, the Child and Adolescent Services Research Center, and the University of Illinois at Urbana-Champaign are conducting this survey.

SELECTION OF CHILDREN

RTI representatives are contacting families of children selected in 2008-2009 from child welfare agencies throughout the United States. We are following up with sampled children and their caregivers approximately 18 months after the initial interview. A child currently or very recently in your care is among over 5,300children randomly selected to be interviewed. That child gave us their permission to approach you for an interview.

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview you about the child and your family. Your answers combined with the answers of other care givers in the study will help us describe the needs of children and their use of available child welfare services. The information will be summarized in research reports and be used to help policy makers improve the child welfare system.

TYPES OF QUESTIONS FOR PARENT

The interview averages 100 minutes. The interviewer will ask questions about the child’s learning, behavior at home and at school, health, and relationships with friends. For older children, we will ask you about their participation in potentially risky behaviors. You will also be asked about services your family or the youth may receive, including your level of satisfaction with those services. In addition, we will ask questions about your attitudes about raising children, life experiences, family support, involvement with school and community activities, your interaction with the child and things that may happen in your family like violence in the home, drug abuse, and other risky behaviors such as drinking, drug use, and involvement with the police.

VOLUNTARY PARTICIPATION

Your participation in this study is completely voluntary. You can refuse to answer any and all questions. Your refusal would not affect any benefits that you or the youth may be receiving. You have the right to stop the interview at any time.

RISKS

There are no physical risks to you from participating in this interview. It is possible that some questions might make you uncomfortable or feel various emotions, such as sadness. If we learn during the course of these interviews that the life or health of a child is in danger, we will share that information with the appropriate county or state agency. More information is provided in the Confidentiality section below.

BENEFITS

There are no direct benefits to you from answering our questions. However, you will be helping us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

To help us understand how the well-being of children changes over time, we or other researchers may contact you and the youth in the future to update our information. Each of these additional interviews will also be completely voluntary.

CONFIDENTIALITY

Your answers will be entered into a computer and labeled with a case identification number. Your name will not be reported with any information you provide. Information you provide will be combined with answers of many others and reported in a summary form. To protect the privacy of both you and the youth, neither of you will know the other’s interview answers. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two important exceptions. (1) If the interviewer or project staff feel that a child’s life or health is in danger, they will inform the appropriate county or state agency. Also, if they feel that your life or health is in serious danger, they will contact emergency assistance. (2) At some point in the future this research may be done by another organization. If that happens, with your consent, we would give contacting information for you and the youth to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at the RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

Because your contribution is important, we will pay you $50 in cash for participating in the interview. If you participate in future rounds, you and the youth will be paid for participating in the in-person interviews.

The above information has been explained to me, and my signature below indicates that I give consent for my interview.

I give consent for having contacting information for me given to another research organization if they start doing this study.

Check one box.

We are using a laptop quality control (QC) system on this study. The system runs on the computer and may record what you and I say to each other during parts of the interview. Neither you nor I will know when the computer is recording our conversation. The recording will be reviewed by project staff at RTI to monitor my work. The recordings will only be used for those purposes and will be kept confidential. The files will be destroyed after they have been used to review my work. Those project staff who listen to the recording will know who I am, but will not know who you are. Is it all right with you if this QC system runs during this interview?

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Caregiver	Signature of Interviewer	Date

Caregiver of Emancipated Youth Permission Form for

Combining NSCAW Data with Other Research Data

Why should I grant permission for my NSCAW data to be combined with other data?

information that exists now, as well as information in the future. We are requesting your permission to add other sources of information to your interview data.

There are two types of data that could be linked to your interview data once it gets back to RTI International. First, we would link your interview data to records collected from participating child welfare services agencies. Adding this information will help us to learn more about any services that you receive. Second, at some point in the future, researchers interested in the NSCAW data may wish to add other information, such as data on state child welfare policies, to your interview data. Your permission would allow these researchers to combine this new information to your interview data.

How will the data be combined and who will it be released to?

The information we obtain from these sources will be combined with the information you give us in the interviews and made available to researchers on a very restricted basis. No personally identifying information about you will be included. Before receiving data, researchers must complete an application that gives good reason for their use of the information. Applications will be reviewed and either approved or denied by a group of individuals whose job it is to protect the rights of people like you who participate in research studies. The information will only be used for reports. Your name will not appear in any of these reports.

What are the risks and benefits associated with granting permission for this request?

The only risk you are taking by giving permission for your NSCAW information to be combined with other information is the small risk that some people who do research and get your information might not follow the rules we set for using your information. There are also no direct benefits for allowing your NSCAW information to be combined with other types of information. Your decision with regard to this request will not affect any services you may be receiving now or in the future. By answering “yes”, you are giving permission for all of the NSCAW information we have ever collected in our interviews to be used in the future for other important research studies that may be approved.

What are my rights with regard to this request?

You have the right to refuse this request. However, we hope you will give us your permission to use your information in this way. If in the future should you decide that you no longer want your information combined with other records, you should contact Pat Crowley at RTI International (RTI) (toll-free at 877-254-1953, extension 67) to record your request.

Check one box.

	Yes, I consent to having all of my NSCAW information ever collected in interviews to be added in the future to information in other important research studies. This permission will take effect when RTI releases information from this round to researchers.

	No, I do not want any of my NSCAW data ever collected in interviews to be added to other information. This refusal request will take effect when RTI releases information from this round to researchers.


Printed Name of Caregiver	Fill in CCG Respondent 8-digit ID #

Signature of Caregiver		Date

Emancipated Youth Consent Form / Permission for Caregiver Interview

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The federal government is funding a national survey of children and families in contact with the child welfare system. RTI International (RTI), a not-for-profit research organization in North Carolina, and staff at ICF Caliber, Walter R. McDonald & Associates, Inc (WRMA), Tufts-New England Medical Center, the Child and Adolescent Services Research Center, and the University of Illinois at Urbana-Champaign are conducting this survey.

SELECTION OF YOUTH

RTI representatives are contacting families of youth, like you, selected from child welfare agencies throughout the United States. You are among over 5,300 youth randomly selected to be interviewed. We are following up with participants approximately 12-14 months after the initial interview.

PURPOSE OF THIS NSCAW INTERVIEW

The interview averages 90 minutes. We want to talk to you about the kinds of things you can do, how you behave at home and at school, how you feel about your family, your friends, and school, and about people who may help you. We also want to ask you about things you may do, such as skipping school, smoking, drinking, vandalism, using drugs, sexual activities, and other risky or illegal behaviors. Your answers, combined with the answers of other youth in the study, will help us describe the needs of children and adolescents and their use of available child welfare services. The information you give will be summarized in research reports and be used to help policy makers improve the child welfare system.

If you are currently living with or have lived with a parent, grandparent, or other adult who took care of you in the last three months, we will request your permission to also talk with that person.

PURPOSE OF THE CAREGIVER INTERVIEW

The interview with the person who took care of you may last up to 100 minutes. He/she will be asked questions about services your family receives, family relationships and support, life experiences, and involvement with school and community activities. He/she will also be asked about your learning, behavior, health, and friendships.

VOLUNTARY PARTICIPATION

Your participation in this study is completely voluntary. If you don’t want to be interviewed, that is okay. If you don’t want to answer a certain question, that is also okay. Your refusal would not affect any benefits that you may be receiving. You have the right to take a break, or stop the interview at any time.

RISKS

There are no physical risks to you from participating in this interview. It is possible that some questions might make you uncomfortable or feel various emotions, such as sadness.

BENEFITS

There are no direct benefits to you from answering our questions. However, you will be helping us learn more about the needs of children and adolescents, and the services available to them.

FUTURE CONTACTS

To help us understand your,needs, and how they change over time, we or other researchers may contact you in the future to update our information. Each of these additional interviews will also be completely voluntary.

CONFIDENTIALITY

Your answers will be entered into a computer and labeled with a number instead of your name so no one else will know these are your answers. No one will see your answers to any of these questions. Your name will not be reported with any information you provide. Information you provide will be combined with answers of many others and reported in a summary form. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two exceptions. (1) If the interviewer or project staff feel that the life or health of a child in your care is in serious danger, they will inform the appropriate county or state agency. Also, if they feel that your life or health is in serious danger, they will contact emergency assistance. (2) At some point in the future this research may be done by another organization. If that happens, with your consent, we would give contacting information for you to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at RTI, 1-877-254-1953 extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI’s Office of Human Research Protections, 1-866-214-2043 (toll-free number).

You will be given a copy of this consent form to keep.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0202 (Exp Date: 05/31/2010). The time required to complete the child interview is estimated to be 120 minutes. The time required to complete the parent interview is estimated to be 100 minutes.

The above information has been explained to me, and my signature below indicates that I give consent for my interview.

I give consent for having contacting information for me given to another research organization if they start doing this study.

Check one box.

I am currently living with or have lived with a caregiver in the last three months and give my permission for my current / most recent caregiver to be approached for an interview.

Check one box.

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Youth	Fill in Youth Respondent 8-digit ID #

Signature of Youth	Signature of Interviewer	Date

Emancipated Youth Consent Request for Combining

NSCAW Information with Other Research Information

What does “combining information” mean?

The information we are getting from you during the NSCAW interviews is very important. It can be even more important when other information about you and your family is added to it. This includes information available now and other information that might become available in the future. We are asking for your okay to add other types of information to the answers you are giving us as part of the interview.

There are two types of information that could be added to your interview answers. First, we would add information collected from the county agency taking part in this study. Adding this information will help us to learn more about any services that you receive. It will also help us learn more about changes in where you live or in the people who care for you. Second, researchers interested in this study may want to add other information to your answers sometime in the future. For example, information on state laws could be added.

How will the information be added and who will be able to use it?

We have a plan for protecting what you have told me, so that the information will not be used against you in any way. Your information would only be used by researchers who request to use it. These requests must be approved by a group of people whose job is to protect the rights of young people like you. We will only share your information with people who can show that they: (1) have a good reason to use the information, (2) will only use the information in their scientific reports, and (3) will not use your name in any of the reports.

What are the risks and benefits for saying it’s OK to do this?

The only risk you are taking by giving permission for your NSCAW information to be added to other information is the small risk that some researchers might not follow the rules we set for using your information. There are no direct benefits to you in giving permission for your NSCAW information to be combined with other types of information. Your decision will not change any services you or your family may be receiving now or in the future. By answering “yes”, you are giving permission for all of the NSCAW information we have ever gotten about you and your family in our interviews to be used in the future for other important research studies.

What are my choices?

You have the right to say “no” to this request. However, we hope you will let us use your information in this way. In the future, if you change your mind about this, you should call Pat Crowley at RTI International (RTI) (toll-free at 877-254-1953 extension 67) to ask that your NSCAW information no longer be used in this way.

Check one box.

	Yes, it’s OK for all of my NSCAW information ever gotten from interviews to be added in the future to information in other important research studies. This permission will take effect when RTI releases information from this round to researchers.

	No, I do not want any of my NSCAW information ever gotten from interviews to be added to other information. This refusal request will take effect when RTI releases information from this round to researchers.


Printed Name of Youth	Fill in Youth Respondent 8-digit ID #

Signature of Youth		Date

Legally Emancipated Youth Authorization for Teacher to Release Information

Teacher Authorization Form

National Teacher Survey of Children and Adolescents

Name of Youth:______________________________________ Case ID#: 

Fill in Youth Respondent 8-digit ID #

By signing this form, I give permission to the Research Triangle Institute (RTI) to contact my primary teacher, language arts teacher, special education teacher, or other classroom instructor who has taught me for at least two months within the current or last school year. I understand that information about my behavior during class time, relationships with classmates, teachers, peers, and involvement in school-related activities such as sports and clubs will be collected. I further understand that questions about school performance and attendance will also be asked.

This information is being requested for a research study I am participating in to learn more about the behavior, learning, development, and needs of children. The study is being funded by the U.S. Department of Health and Human Services (DHHS) and is being conducted by RTI.

Print Date One Year From Today Above

______________________________________________________________________________________________

The above information has been explained to me and I give permission to my teacher to release information to the researchers involved in this study.

PLEASE PRINT CLEARLY

Youth’s Name: ________________________________________________________

FIRST LAST

Name of Youth’s Teacher:

Mr/Ms __________________________________________________

FIRST LAST

Name of Principal: Mr/Ms __________________________________________________

FIRST LAST

Name of School: ________________________________________________________

Address of School:

________________________________________________________

NUMBER AND STREET

________________________________________________________

CITY STATE ZIP

School Phone Number: ( )___________________________________________________

___________________________________ ______________________

Signature of Legally Emancipated Youth Date

Note: The above youth is legally emancipated according to governing state laws and has the authority to consent to this

information release.

Young Adult Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The federal government is funding a national survey of children, young adults, and families in the child welfare system. RTI International (RTI), a not-for-profit research organization in North Carolina, and staff at ICF Caliber, Walter R. McDonald & Associates, Inc (WRMA), Tufts-New England Medical Center, the Child and Adolescent Services Research Center, and the University of Illinois at Urbana-Champaign are conducting this survey.

SELECTION OF SAMPLE MEMBERS

RTI representatives are contacting young adults, like you, selected from child welfare agencies throughout the United States in 2008 or 2009. You are among over 5,300 youth randomly selected to be interviewed. We are following up with participants approximately 12-14 months after the initial interview.

PURPOSE OF THIS NSCAW INTERVIEW

The interview averages 90 minutes. The interviewer will ask questions about your life experiences. The questions will focus on your health, employment, relationships, social support system, behaviors, and use of services. The interviewer will also ask you about the community in which you live, and about things that may happen in your life like violence in the home, drug abuse, and other risky behaviors such as drinking, sexual activity, drug use, and involvement with the police. Your answers combined with the answers of other young adults in the study will help us describe the transition to adulthood and outcomes of young people who have come into contact with the child welfare system. The information will be summarized in research reports and be used to help policy makers improve the child welfare system and available services.

VOLUNTARY PARTICIPATION

Your participation in this study is completely voluntary. You can refuse to answer any and all questions. Your refusal would not affect any benefits that you may be receiving. You have the right to stop the interview at any time.

RISKS

There are no physical risks to you from participating in this interview. It is possible that some questions might make you uncomfortable or feel various emotions, such as sadness.

BENEFITS

There are no direct benefits to you from answering our questions. However, you will be helping us learn more about the needs of young adults and the services available to them.

FUTURE CONTACTS

To help us understand how the well-being of young adults changes over time, we or other researchers may contact you in the future to update our information. Each of these additional interviews will also be completely voluntary.

CONFIDENTIALITY

Your answers will be entered into a computer and labeled with a case identification number. Your name will not be reported with any information you provide. Information you provide will be combined with answers of many others and reported in a summary form. All staff involved in this research are committed to confidentiality and have signed a Confidentiality Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

There are two important exceptions. (1) If the interviewer or project staff feel that the life or health of a child in your care is in serious danger, they will inform the appropriate county or state agency. Also, if they feel that your life or health is in serious danger, they will contact emergency assistance. (2) At some point in the future this research may be done by another organization. If that happens, with your consent, we would give contacting information for you to the other organization.

QUESTIONS

If you have any questions about the study, you may call Pat Crowley at RTI, 1-877-254-1953 Extension 67 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will be given a copy of this consent form to keep.

The above information has been explained to me, and my signature below indicates that I give consent for my interview.

I give consent for having contacting information for me given to another research organization if they start doing this study.

Check one box.

	Yes, I consent to having portions of this interview recorded by the computer to test the quality control system.

	No, I do not want any portion of this interview recorded.


Printed Name of Young Adult	Fill in YA Respondent 8-digit ID #

Signature of Young Adult	Signature of Interviewer	Date

Young Adult Consent for Combining

NSCAW Information with Other Research Information

Why should I grant permission for my NSCAW data to be combined with other data?

All of the information we have collected from or about you during the NSCAW interviews can be even more valuable to researchers if it can be combined with other information on you that we obtain from sources outside this survey –information that exists now, as well as information in the future. We are requesting your permission to add other sources of information to you and your child’s interview data.

There are two types of data that could be linked to your interview data once it gets back to RTI International. First, we would link your interview data to records collected from participating child welfare services agencies. Adding this information will help us to learn more about any foster care or other services that you receive. Second, at some point in the future, researchers interested in the NSCAW data may wish to add other information, such as data on state child welfare policies, to your interview data. Your permission would allow these researchers to combine this new information to your interview data.

How will the information be added and who will be able to use it?

The information we obtain from these sources will be combined with the information you give us in the interviews and made available to researchers on a very restricted basis. No personally identifying information about you will be included. Before receiving data, researchers must complete an application that gives good reason for their use of the information. Applications will be reviewed and either approved or denied by a group of individuals whose job it is to protect the rights of people like you who participate in research studies. The information will only be used for reports. Your name will not appear in any of these reports.

What are the risks and benefits associated with granting permission for this request?

The only risk you are taking by giving permission for your NSCAW information to be added to other information is the small risk that some researchers might not follow the rules we set for using your information. There are no direct benefits to you in giving permission for your NSCAW information to be combined with other types of information. Your decision will not change any services you may be receiving now or in the future. By answering “yes”, you are giving permission for all of the NSCAW information we have ever collected in our interviews with you to be used in the future for other important research studies.

What are my choices?

You have the right to refuse this request.. However, we hope you will let us use your information in this way. In the future, if you change your mind about this, you should call Kathryn Dowd at Research Triangle Institute (RTI) (toll-free at 877-254-1953 Extension 59) to ask that your NSCAW information no longer be used in this way.

Check one box.

	Yes, I consent to having all of my NSCAW information ever collected in interviews to be added in the future to information in other important research studies. This permission will take effect when RTI releases information from this round to researchers.

	No, I do not want any of my NSCAW information ever collected in interviews to be added to other information. This refusal request will take effect when RTI releases information from this round to researchers.


Printed Name of Young Adult	Fill in Young Adult Respondent 8-digit ID #

Signature of Young Adult		Date

Case ID#: _____________________

Caregiver Authorization for Use or Disclosure of Health Information

National Survey of Child and Adolescent Well-Being (NSCAW)

Child Name:

First Middle Last

Child's Date of Birth: _____/___/____

Month/Day/Year

I, the undersigned, authorize the disclosure of individually identifiable health information about my child for research, as described below.

Description of information to be disclosed, including dates of service related to such information:

Information about Medicaid services that may have received, including: (Child Name – First, Middle, Last)

Date of Service
Type of Inpatient or Outpatient Service
Type of Provider or Health Care Professional (e.g., physician, nurse, psychologist, etc.)
Medications Prescribed
Insurance Coverage

Provider authorized to disclose my child’s health information (provider name and address):

U.S. Department of Health and Human Services

Centers for Medicare and Medicaid Services

Persons or class of persons to whom my child’s health information may be disclosed:

NSCAW research staff at RTI International, Research Triangle Park, NC

Purpose for this disclosure of my child’s health information:

We would like to better understand the types of services that your child may be receiving. Linking your child’s survey data to information on Medicaid services will allow researchers to have a more complete picture of the types of services used and who is providing those services. Only NSCAW research staff at RTI International will have access to your child’s health information. All identifying information will be destroyed after data files are electronically merged for research purposes.

This authorization expires:

18 months after the date of this interview: _____/___/____

Month/Day/Year

I understand that I may revoke this authorization at any time by notifying RTI International in writing at the following address:

3040 Cornwallis Road
Post Office Box 12194
Research Triangle Park, NC 27709-2194

I also understand that I may refuse to sign this authorization and that my refusal will in no way affect my or my child’s treatment, payment, enrollment in a health plan, or eligibility for benefits.

By signing below, I give permission to the provider named above to release health information about my child to NSCAW staff at RTI International.

Printed Name of Child’s Parent/Guardian:

First Middle Last

Signature of Child’s Parent/Guardian:

Date: _____/___/____

Month/Day/Year

Case ID #:_____________________

Legal Guardian Authorization for Use or Disclosure of Health Information

National Survey of Child and Adolescent Well-Being (NSCAW)

Child Name:

First Middle Last

Child's Date of Birth: _____/___/____

Month/Day/Year

I, the undersigned, authorize the disclosure of individually identifiable health information about the child named above for research, as described below.

Description of information to be disclosed, including dates of service related to such information:

Information about Medicaid services that may have received, including: (Child Name – First, Middle, Last)

Date of Service
Type of Inpatient or Outpatient Service
Type of Provider or Health Care Professional (e.g., physician, nurse, psychologist, etc.)
Medications Prescribed
Insurance Coverage

Provider authorized to disclose the child’s health information (provider name and address):

U.S. Department of Health and Human Services

Centers for Medicare and Medicaid Services

Persons or class of persons to whom the child’s health information may be disclosed:

NSCAW research staff at RTI International, Research Triangle Park, NC

Purpose for this disclosure of the child’s health information:

We would like to better understand the types of services that the child may be receiving. Linking the child’s survey data to information on Medicaid services will allow researchers to have a more complete picture of the types of services used and who is providing those services. Only NSCAW research staff at RTI International will have access to the child’s health information. All identifying information will be destroyed after data files are electronically merged for research purposes.

This authorization expires:

18 months after the date of this interview: _____/___/____

Month/Day/Year

I understand that I may revoke this authorization at any time by notifying RTI International in writing at the following address:

3040 Cornwallis Road
Post Office Box 12194
Research Triangle Park, NC 27709-2194.

I also understand that I may refuse to sign this authorization and that my refusal will in no way affect the child’s treatment, payment, enrollment in a health plan, or eligibility for benefits.

By signing below, I give permission to the provider named above to release health information about the child to NSCAW staff at RTI International.

Printed Name of Child’s Legal Guardian:

First Middle Last

Signature of Child’s Legal Guardian:

Date: _____/___/____

Month/Day/Year

File Type	application/msword
File Title	National Survey of Child and Adolescent Well Being
Author	dbond
Last Modified By	DHHS
File Modified	2009-06-23
File Created	2009-06-23