Head Start core parent consent form

APPENDIX C-1

PARENT CONSENT FORM (web-first group)

FACES CONSENT FORM

We invite you and your child to take part in the Head Start Family and Child Experiences Survey 2014–2018 (FACES). We are inviting you because your child is in a Head Start program that is taking part in this study. FACES aims to learn more about families in Head Start and the services Head Start provides. This study will help Head Start serve all children and their families. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is funding FACES. Mathematica Policy Research, an independent firm, is conducting the survey.

If you agree to take part…

We will ask you to complete a survey this fall and in spring 2015 via the web. We will ask you about your child, your family’s activities and routines, your feelings, and your health. These surveys will take about 20 minutes. We will conduct them in your language.

We will do some activities with your child so we can find out how Head Start helps children learn and grow. This fall and next spring, we will ask your child to do some fun activities with a trained researcher. For example, we will ask your child to look at pictures, copy drawings, and answer questions. This will take about 45 minutes. We will do the activities in English or if your child speaks Spanish, we can do the activities in whichever language your child knows best.

We will offer tokens of appreciation for your help. After you complete the survey online, as a thank you, we will send you a $20 gift card. If you do not have internet access, you can complete the survey at your child’s Head Start center during the week the FACES data collection team is present. If you complete the survey within three weeks of being asked to do so, you will receive an additional $5, for a total of $25. After your child completes the activities, we will give him or her a children’s book as a special thank you.

We will ask your child’s Head Start teachers some questions about your child and will observe your child’s classroom. This will help us learn more about the progress your child is making in Head Start.

You can choose whether you and your child will be part of the study. Your participation is completely voluntary. All information collected during the course of FACES will be kept private to the extent permitted by law. Your choice will not affect the Head Start services you and your child receive. If at any point you decide to leave the study, that is okay. No one from Head Start will see or hear your answers or learn about how your child does on the activities. We will only report the results for parents and children as a group. However, if we learn that a child has been hurt or is in danger, we must by law report this to the appropriate authorities. This could result in legal action.

If you have questions about FACES, please call us toll free at 1-888-XXX-XXXX. A staff member will be happy to talk with you. If you have questions about your rights as a research volunteer, please call the New England Institutional Review Board toll free at 1-800-233-9570. You can find out more about FACES on the FACES website. Visit http://www.acf.hhs.gov/programs/opre/hs/faces.

We hope you will take part in this study. Please sign the attached consent form and return it to your child’s teacher right away. Thank you!

I have read this consent form and understand what I am being asked to do.

I agree to have my child take part in this study. I also agree to have FACES researchers collect some information from my child’s Head Start teacher. I will receive a $20 gift card after each time I complete a survey online. If I complete a survey within three weeks of being asked to do so, I will receive an additional $5, for a total of $25. My child will also receive a children’s book each time he or she is assessed. I may withdraw this consent at any time without penalty.

1. Child’s name (print)

2. Parent/guardian signature Today’s date

3. Parent/guardian name (print)

4. Your relationship to child  Mother  Father  Grandmother  Other guardian

5. Home phone ( )___________________

6. Cellular/other phone ( )___________________

6a. Does your cellular phone plan have unlimited minutes?*

 Yes  No

6b. May we send you text messages?*

 Yes  No

7. Email address

8. Do you have access to a smart phone, laptop, computer or other device that gives you access to the Internet?

 Yes  No

9. Child’s gender  Male  Female

10. Child’s birthday

Month Day Year

11. What language does your child use most often at home?

 English  Spanish  Other

12. What language would you like to use to complete your survey?  English  Spanish  Other

*We may text or call you to remind you about the parent survey or child assessment.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Jerry West.

APPENDIX C-2

PARENT CONSENT FORM (CHOICE GROUP)

FACES CONSENT FORM

We invite you and your child to take part in the Head Start Family and Child Experiences Survey 2014–2018 (FACES). We are inviting you because your child is in a Head Start program that is taking part in this study. FACES aims to learn more about families in Head Start and the services Head Start provides. This study will help Head Start serve all children and their families. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is funding FACES. Mathematica Policy Research, an independent firm, is conducting the survey.

If you agree to take part…

We will ask you to complete a survey this fall and in spring 2015 via the web or over the phone. We will ask you about your child, your family’s activities and routines, your feelings, and your health. These surveys will take about 20 minutes. We will conduct them in your language.

We will do some activities with your child so we can find out how Head Start helps children learn and grow. This fall and next spring, we will ask your child to do some fun activities with a trained researcher. For example, we will ask your child to look at pictures, copy drawings, and answer questions. This will take about 45 minutes. We will do the activities in English or if your child speaks Spanish, we can do the activities in whichever language your child knows best.

We will offer tokens of appreciation for your help. You will have the option to do the survey by phone or on the web. If you do not have internet access, you can complete the survey at your child’s Head Start center during the week the FACES data collection team is present. After you complete the survey, as a thank you, we will send you a $15 gift card. If you complete the survey within three weeks of being asked to do so, you will receive an additional $5. If you complete the survey on the web, you will receive an additional $5. Therefore, if you complete the survey on the web within the first three weeks, you could receive a total of $25.. After your child completes the activities, we will give him or her a children’s book as a special thank you.

We will ask your child’s Head Start teachers some questions about your child and will observe your child’s classroom. This will help us learn more about the progress your child is making in Head Start.

You can choose whether you and your child will be part of the study. Your participation is completely voluntary. All information collected during the course of FACES will be kept private to the extent permitted by law. Your choice will not affect the Head Start services you and your child receive. If at any point you decide to leave the study, that is okay. No one from Head Start will see or hear your answers or learn about how your child does on the activities. We will only report the results for parents and children as a group. However, if we learn that a child has been hurt or is in danger, we must by law report this to the appropriate authorities. This could result in legal action.

If you have questions about FACES, please call us toll free at 1-888-XXX-XXXX. A staff member will be happy to talk with you. If you have questions about your rights as a research volunteer, please call the New England Institutional Review Board toll free at 1-800-233-9570. You can find out more about FACES on the FACES website. Visit http://www.acf.hhs.gov/programs/opre/hs/faces.

We hope you will take part in this study. Please sign the attached consent form and return it to your child’s teacher right away. Thank you!

I have read this consent form and understand what I am being asked to do.

I agree to have my child take part in this study. I also agree to have FACES researchers collect some information from my child’s Head Start teacher. I will receive a $15 gift card after each time I complete a survey. If I complete a survey within three weeks of being asked to do so, I will receive an additional $5. If I complete a survey on the web, I will also receive an additional $5. Therefore, if I complete the survey on the web within the first three weeks, I could receive a total of $25. My child will also receive a children’s book each time he or she is assessed. I may withdraw this consent at any time without penalty.

1. Child’s name (print)

2. Parent/guardian signature Today’s date

3. Parent/guardian name (print)

4. Your relationship to child  Mother  Father  Grandmother  Other guardian

5. Home phone ( )___________________

6. Cellular/other phone ( )___________________

6a. Does your cellular phone plan have unlimited minutes?*

 Yes  No

6b. May we send you text messages?*

 Yes  No

7. Email address

8. Do you have access to a smart phone, laptop, computer or other device that gives you access to the Internet?

 Yes  No

9. Child’s gender  Male  Female

10. Child’s birthday

Month Day Year

11. What language does your child use most often at home?

 English  Spanish  Other

12. What language would you like to use to complete your survey?  English  Spanish  Other

* In case you would like to complete your parent survey using your cell phone. Also, we may text you to remind you about the parent survey or child assessment.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 control number for this collection is 0970-0151 and it expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Jerry West.