Parental Permission form

Appendix A.2.- The Family Options Study

Parent Permission Form—Children 3 ½ -17 years of age

About 3 years ago, you agreed to participate in a study sponsored by The US Department of Housing and Urban Development (HUD). The study is about housing and services interventions for families who experience homelessness. This study is often referred to as the Family Options Study. Abt Associates, an independent research company, is partnering with Vanderbilt University and Abt SRBI, to conduct this study.

You may recall participating in an interview about 18 months ago. At that time we also asked for your permission for your child or children to participate in some games and activities as part of that study. At this time, we are verifying that you would like your child or children to continue to participate in the study.

Purpose of the Study

This study will look at the effects different housing and services interventions have on the health and well-being of children who have experienced homelessness. The study will collect data from children 3 years 6 months -7 years of age through a series of games and activities. The study will also collect data from children 8-17 years of age through a short survey.

For children ages 3 years and 6 months to 7 years of age, we anticipate that the assessments will take about 50 minutes to complete. Examples of some things that we may ask your child to do include: 1) an activity where the child does some letter or number recognition, 2) a game where he or she will be asked to the same or the opposite activity that the interviewer does and/or 3) some problem solving tasks. These activities should be fun and interesting for your child. These activities will help us understand how different housing situations affect children’s development. We do ask that the parent stays out of the child’s sight during these activities to ensure that the child is not distracted and so the child does not try to ask you for help with the tasks.

For children ages 8 to17 years of age, we will ask them to participate in a short interview. The interview should last about 30 minutes. The short interview will cover various topics such as school, fears, life events, how he/she feels about him/herself, and his/her relationship with a caregiver. You should know that all youth will be asked some sensitive questions. Some of the questions will be about substance use and gang involvement. Children 13-17 years of age will be asked a more in-depth set of questions about frequency of alcohol, drug, or tobacco use. Your child may find some of these questions personal or embarrassing. We will try to make sure that your child is comfortable during the interview.

We will remind your child that participating in the interview or the activities is voluntary and that no one will see his/her answers, including you. We will tell your child that you as his/her parent or guardian gave us your permission to talk with your child, but explain that your child may choose not to answer any of the questions and may stop the interview or activities at any time. You, as his or her parent, may also stop the interview or activities at any time. If you or your child choose not to participate there will be no penalty. We do ask that you not be present in the room as your child participates in the interview to ensure privacy. Abt Associates expects to conduct interviews/assessments with roughly 3,010 children in approximately 2,300 families around the nation. In appreciation for the time your child spent participating in this study we will give you a $25 money order.

Does My Child Have to Participate?

Your child’s participation in this study is completely voluntary. Your child can choose not to answer any question. Your child can stop the interview or assessment at any time. The housing or other assistance you may receive will not be affected if your child does not participate. If you decide that you do not want your child to participate in the study that is okay. You will still be part of the original study that you enrolled in approximately 3 years ago. There are no financial costs to you or your child for your child participating in this study.

If I sign this parental permission form, to what else am I agreeing?

If you sign this parental permission form, you give your permission for your child to participate in this study.

Abt Associates staff may continue to contact you in the future to see if your contact information has changed or to request additional interviews to find out how things are going. All of these follow-up activities with Abt Associates will also be voluntary.

CONFIDENTIALITY: Who will see the information provided?

All information your child provides is confidential. Any information that the researchers collect about your child will be kept confidential and protected to the extent allowed by the Privacy Act.¹ Special efforts have been taken to protect your child’s privacy and to ensure that any confidential information that he or she may share is not accidentally disclosed. This study has a special certificate from the U.S. government. This certificate adds extra protection for the research information that identifies your child. This certificate does not mean the government approves or disapproves of this study. It says that the research team does not have to identify you or your child or provide any information about you or your child, even if a court asks them to. Your child’s information will be protected to the extent allowed under the law as part of the Privacy Act. (This means, for example, that the researchers may need to notify someone if keeping the information confidential could put your child or others at risk of harm).

No one at the housing program to which you were assigned when you joined the study will see your child’s information. Your child’s name will never be used in any report. Reports for this study will only show summaries, no names or individual identifying information will ever be used in any research report.

Only the following people will see your personal identifiers:

• The interviewer conducting this survey

• A small number of Abt research staff authorized to work on the Family Options Study.

Are there any risks to your child if he/she participates in this study?

There are minimal risks to your child from participating in these activities. He or she may feel a bit upset if they find the activities difficult. Remember, your child’s participation in the activities is voluntary. Interviewers will help ensure that your child is comfortable. First, they will remind your child that he or she can decide if they want to do the activities or not. Your child may refuse to answer any of the questions or stop the activity at any time. You, as his or her parent, may also stop the activities at any time.

The study has strict procedures in place to protect the information you provide. However, there is some risk that your child’s information could be released inadvertently to people other than the researchers doing this study. If that were to happen, we would contact you to let you know that this occurred.

Questions About Participation

If you have questions regarding this study, please contact the Survey Director Ms. Brenda Rodriguez at 617-386-2603. You may also contact the Abt Associates Inc. Project Director, Ms. Michelle Wood at 301-634-1777. (These are not toll-free numbers). You may also call the study toll-free line at 1-800-320-9193.

If you have any questions about your child’s rights as a participant in this study, you can call Ms. Katie Speanburg, the Abt Associates Institutional Review Board (IRB) Administrator, toll free at (877) 520-6835.

Statement of Permission

Before giving my permission by signing this form, I confirm that I have read this form or had it read to me. The information in this form has also been explained to me. I have had the opportunity to ask questions. I understand the information presented in this form. I understand that my child’s participation is voluntary, and he/she can ask to be withdrawn from the study at any time. I understand that even though I give my permission for my child to participate, my child can still decide not to participate in the research. I also understand that there will be no penalty if me or my child refuse to participate in this research. I understand that I will be given a signed copy of this permission form to keep. I voluntarily agree to give permission for my child to take part in this study of programs for homeless families and child outcomes.

Participant Study ID____________________________

___________________________________________

Parent or Legal Guardian’s Name—Please Print

____________________________________________ ________________________

Signature of Parent or Legal Guardian Date

___________________________________________ ________________________

Focal Child 1 Name—Please Print Child’s Date of Birth

___________________________________________ ________________________

Focal Child 2 Name—Please Print Child’s Date of Birth

____________________________________________

Name of Interviewer

____________________________________________ ________________________

Signature of Interviewer Date

COMPLETE IF INTERVIEW COMPLETED BY PHONE:

Verbal Consent Obtained: YES NO

____________________________________________

Name of Interviewer

____________________________________________ ________________________

Signature of Interviewer Date

1 Privacy Act Statement: HUD’s authoritative and principle purpose, conditions of uses, and impacts, if any, for not participating in the survey are referenced within the participant agreement. HUD’s statutory authority for collecting this data can be found at Section 502 (g) of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. 1701z-1; 1701z-2(d) and (g)).