Administrative Records Consent Form

OMB# 0970-0388
Expires: 10/1/2015

Dear
We are writing to you on behalf of the Early Head Start Follow-up Study. This is the project you started
with (FILL SITE NAME) when you were a baby. As you might remember, The Early Head Start Follow-up
Study is a long term project evaluating early childhood programs that you and your family may have
been a part of.
Thanks to your participation over the years, we have learned a lot about children’s growth and
development. The project has been so successful and the information has been so valuable that the
government hopes to continue its research to learn how participation in Early Head Start or other child
care programs affects children and their families when children are older.
The Administration of Children and Families (ACF) is asking for your permission to access your school
and juvenile justice records to help look at how these early childhood programs affect kids and their
families as they get older. ACF will only use this form to access your school and juvenile justice
administrative records if (and only if) the government decides to continue the Early Head Start Followup Study. The records cannot be accessed or used for any other purpose. Any information collected
from your school and/or juvenile justice records will be kept private to the extent permitted by law.
Reading and returning this form should only take about 5 minutes. After we receive your updated
contact information, we will send you $5. All of the information you provide will be shared ONLY with
researchers working on the Early Head Start Follow-up Study and kept private to the extent permitted
by law.
If you have any questions about this project, please take a look at the brochure that was included with
this letter or give us a call on our toll-free line, (888) 800-3748.
Sincerely,

ATTACHMENT J Administrative Records Consent Form.doc

OMB# 0970-0388
Expires: 10/1/2015

AUTHORIZATION FOR
THE ADMINISTRATION FOR CHILDREN AND FAMILIES (ACF)
TO OBTAIN EDUCATION AND JUVENILE JUSTICE RECORDS

Date:

Pursuant to Federal guidelines concerning my right to privacy, I
_________________
(Name of Student)
give my permission to release the following records to the Administration for Children and
Families:
 Academic and Behavioral information as it relates to:

(School Attended)

_____________________
(Period of Time)

_____________
Initials

_____________________
(Period of Time)

_____________
Initials

Juvenile Justice records as they relate to:

(County/State Agency)

The information obtained from these records will be used to determine the impact of services provided
under the Early Head Start Program.
I understand that I may revoke this consent form to release information at any time. However, if
information has already been released by the above school district and/or County or state agency
prior to my revocation and was made in reliance under this authorization to release, the above release
of information form does not constitute a breach of privacy.
It is agreed upon receipt of these records, the study will not release the records (except in instances when
your name and identifying information has been removed) or any information therein to any other person
or agency without your prior written consent. You may request a copy of these records. If you desire a
copy, make this known to the custodian of the records.

(Name of Student)

Signature

Date

This collection of information is voluntary and will be used to maintain up-to-date contact information on the participants of the Early Head
Start Research and Evaluation Project. Public reporting burden for this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. The OMB number for this information collection is 0970-0388 (Exp. 10/1/15). Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Amy
Madigan; ACF / OPRE, 370 L’Enfant Promenade SW, 7th floor West, Washington, DC 20447; Attn: OMB-PRA (0970-0388).

ATTACHMENT J Administrative Records Consent Form.doc