Hybrid_HV-SPConsent_Form August 27 2012

OMB Control No: 0970-0402

Expiration date: 7/31/2015

A

Mother and Infant Home Visiting Program Evaluation

greement for Staff who are Supervisors and Home Visitors to Take Part in the

We would like you to take part in an important research project to learn more about the effects of home visiting services. The project is being funded by the US Department of Health and Human Services. MDRC is conducting the study with James Bell Associates, Johns Hopkins University, and Mathematica Policy Research. The study will give States and the federal government information to help them improve their services for parents with young children.

What does it mean to be in the study?

About 100 home visiting supervisors and 510 home visitors will be in the study around the country. Home visiting staff members in 12 states are being asked to provide information to help improve home visiting programs.

If you agree to take part in the study, we will ask you to do the following:

• Complete a web-based survey today.

• This survey will take about one hour and 45 minutes to complete.

• We will want to learn about you, your home visiting and supervision experience, and your home visiting and supervision training. We will ask you to answer questions online about employment and supervision, roles and responsibilities, program outcomes, program referrals, knowledge of child development and professional consultation. We will also ask you some demographic questions and questions about your psychological well-being.

• You will receive $40 for completing the survey.

• Complete a web-based survey in the future.

• In one year, you will be asked to complete a similar online survey. The survey will take about one hour and 45 minutes to complete.

• You will receive $40 for completing any future survey.

• Agree to be videotaped during some selected home visits with families in your caseload in the future.

• We may ask to video record home visits between you and families in your caseload on some occasions. These videos will be used for research and research training purposes only.

Risks and Benefits

Participating in the study will help local, state, and federal agencies improve their home visiting services.

You will receive $40 each time you complete a web-based survey.

Some of the questions we ask involve sensitive topics. They may be stressful to answer. You may refuse to answer any questions, both today and in the future. There is a small risk that the information you sharing will be disclosed outside the study team. However, the study team follows strict rules to protect your privacy and we will keep your information private. No reports will include your name or other personally identifiable information. The information you give us will not be provided to your home visiting program in a way that could identify you.

Being part of the study is your choice

Taking part in the study is your choice. If you decide not to be in the study, there is no penalty. Your decision will not affect your employment with the home visiting program.

You may stop being in the study at any time. You may refuse to answer any questions we ask, both today and in the future. You may refuse to be recorded during home visits.

Information will be private

The research team follows strict rules to keep your information private. All study staff are trained to protect privacy and sign a confidentiality pledge. All of your answers in the survey will remain private. If keeping your answers private would put you or someone else in serious danger, then we will have to tell the appropriate agencies to protect you or the other person.

All information about you will be marked with a code number, not your name. No reports will describe you in a way that would allow you to be identified. We have to deliver the study data to the federal government at the end of the study, but the data file will not contain information that could be used to identify you.

If you have questions at any time during the study, please call MDRC toll-free at 1-877-311-6372.

Subject’s Statement:

“The research procedures, risks and benefits have been explained to me. I recognize that I am free to ask any questions. I understand that taking part in this study is my choice, and that being in it or not being in it will not affect my employment with the home visiting program. I understand that I am free to stop taking part in the study at any time. I understand that I can refuse to answer any question in the survey. I understand that any information that could be used to identify me will be kept private”.

Checking this box will serve as your consent to take part in this research study.

MIHOPE NS-7/18/2012