CAPP Parent-Legal Guardian Questionnaire

Permanency Innovations Initiative (PII) Evaluation - Phase 4

Attachment A3a Parent-Legal Guardian Informed Consent and Questionnaire Paper Scantron 10-15

CAPP Parent-Legal Guardian Questionnaire

OMB: 0970-0408

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CAPP Parent and Legal Guardian Informed Consent
Official Title of Project: Evaluation of the Permanency Innovation Initiative: California Partners
for Permanency II
Principal Investigator: Dr. George Gabel
Institution Conducting the Research: Westat
Date
Dear Potential Participant,
The U.S. Department of Health and Human Services has asked Westat, a research organization,
to do a study on how child welfare services are helping families like yours. They want to know if
the services you receive help children safely stay out of foster care or safely leave foster care
sooner. One of the ways you can help us learn to better serve you and your children is by filling
out the enclosed questionnaire.
If you agree to participate, please fill out the questionnaire, put it in the enclosed pre-paid
envelope, and drop it in any United States Postal Service mailbox. You will be mailed a $50.00
Visa gift card to thank you for your time and responses.
Your responses will not be provided to your social worker, cannot be used in court and will
not affect your child welfare case.
Thank you for your participation.
Frequently Asked Questions
What is the study for?
The study will help us learn if the services you get from child welfare help your children safely
stay out of foster care or safely leave foster care sooner.
How do I participate? How does the study work?
We are asking you to agree to let Westat gather information about you and your family. Westat
will get this information through this questionnaire. The questionnaire asks questions about how
you work with your social worker and the support and service you receive from your social
worker. Other questions will be about other family members’ and friends’ involvement with your
child’s case and how hopeful you feel about your child returning home.
The questionnaire will take about 36 minutes to answer. You can skip questions that you do not
feel comfortable answering. There are no right or wrong answers. We just want you to answer
the questions honestly. If you do not answer all the questions on the survey, or if we cannot
understand your answers, Westat may contact you by telephone or mail to better understand
your responses.

What are the possible risks and discomforts?
This questionnaire has questions that may make you feel upset or uncomfortable. If that happens
please speak to your social worker. You can also skip questions that you do not want to answer.
Will everything I tell you during the study be kept private?
We will keep your information private to the extent permitted by law. We will not include
information that specifically names you or your family in any reports. All responses will be
compiled with responses from other families and will be used for research only.
To help us keep your information private, we received a Certificate of Confidentiality from the
U. S. Department of Health and Human Services. With this Certificate, no one can force us to
share information that may identify you, even in any court or legal proceeding or under a court
order or subpoena. We are mandated reporters, so if we are informed of any abuse or neglect we
are required by law to report this information to child welfare. We are also required to report to
authorities if we are concerned that you might harm yourself.
What are the benefits to participating in the study?
Your participation will help (insert CAPP agency name) find better ways to serve families and
children.
Are there other ways to participate in the study?
There are no other ways to participate in the study other than completing this questionnaire.
Could I be injured by participating in the study?
We do not expect that you will experience any injuries because of participating in the study.
Therefore, no treatment will be available to address any injuries.
Does Westat have a conflict of interest with the Department of Social Services (DSS)?
Westat has no financial or other relationships with (insert CAPP agency name)that will affect
conducting this study, including interpreting and reporting the study results.
Will I get anything for taking part in the study?
We will mail you a $50.00 Visa gift card to thank you for participating once we receive your
mailed survey.
I would like to participate in the study, but I have questions. Who can I contact?
If you have any questions about the study, or would like to complete the questionnaire by
telephone, please call Westat at 1-855-538-6735. They are available from 9:00 a.m. to 3:00 p.m.
PST and are happy to speak with you.
If you have any questions about your rights as person taking part in the study, please contact the
Committee for the Protection of Human Subjects at (916) 326-3660. You can also learn more
about your rights as a part of the study from the Research Participant’s Bill of Rights document in
this packet.

Do I have to take part in the study?
You do not have to be in the study. You can stop being in the study at any time. Your choice will
not affect your case or the services that you and your family get. We hope that you will be part of
the study so that we can learn ways to better serve families.
Participation Decision
I have received a copy of the Research Participant’s Bill of Rights, and I agree to take part in the
survey.
 Yes

 No

If you answered yes to the question above, please sign below and proceed to complete the
questionnaire.
__________________________________________________
Print Your Name Here
______________________________________________
Signature

________________________
Date

Mailing Address for Incentive
Please list the address for Westat to mail the $50.00 Visa gift card.
Name:

_____________________________________________________________________

Address Line 1:________________________________________________________________
Address Line 2: _______________________________________________________________
City, State Zip: ________________________________________________________________
Phone (please include area code): ( ___________ ) – ___________ – ____________________
Date of IRB approval of this consent: TBD
Expiration date of IRB approval of this consent: TBD
OMB NO: TBD
EXPIRATION DATE: TBD
Burden Statement: Public reporting burden for this collection of information is estimated to
average .6 hours per respondent. These estimates include the time for reviewing instructions, and
completing 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.

Participant’s Bill of Rights for Non-Medical Research
You have been asked to participate in a research study. Any participant in a research study has
the right to:
a. Be told the nature and purpose of the study.
b. Be given an explanation of what will happen during the study and of how the research
participant is expected to participate.
c. Be given an explanation of any risks or discomforts that may be experienced as a result of
participating in the study.
d. Be given an explanation of any benefits that may be expected from participation in the
study.
e. Be told of other appropriate choices that may be better or worse than being in the study,
and be told of the risks and benefits of those other choices.
f. Have the opportunity to ask questions about the study or about your participation in it,
both before agreeing to participate in the study and during the course of the study.
g. Be told that you may withdraw your consent and participation in the study at any time,
and that your withdrawal will not affect your services.
h. Be told that you may refuse to answer any question.
i. Be given a copy of the signed and dated consent form.
j. Be free of pressure when considering whether to consent to, and participate in, the study.
k. Be informed, upon request, about the results of the study.

CAPP Parent and Legal Guardian Questionnaire
Instructions
Please use a black or blue pen to complete this form.
Mark

to indicate your answer.

If you want to change your answer, mark

on the wrong answer.

Your answers are very important to us, please print clearly in uppercase letters.
Thank you for answering the questions on this questionnaire. Many of the questions will ask you about your child who is
involved in Child Welfare Services, sometimes called "CPS", and the social worker at <> who has been working
with you and your family.
If you have more than one child in Child Welfare Services, please answer these questions with the social worker of your
child in mind.

What is the name of your child in Child Welfare Services?

What is the name of their social worker?

Please think about these two individuals above whenever you are asked about "the social worker" or "your child." Your
responses will not be provided to your social worker, cannot be used in court, and will not affect your child welfare
case.

Section A
Please think about your experiences with the social worker you named at the beginning of the questionnaire, and your
response to the following statements. Please
your response.
1. In the last 3 months, this social worker has taken
the time to listen to things I have to share about
my family.

2. In the last 3 months, this social worker has kept
me informed about appointments, meetings and
court dates.

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

CAPP Parent-Youngest_IRB draft_v8

Draft

-E

3. In the last 3 months, this social worker has asked
about relatives and other people in my life who
are helping me.

7. In the last 3 months, this social worker has
respected my family's values, beliefs, culture and
traditions when making decisions about supports
and services for us.

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

4. In the last 3 months, this social worker has asked
me about supports and services that my child
needs.

8. In the last 3 months, this social worker has tried to
understand the things that have had a major impact
on our family.

a. Very much so
b. For the most part

a. Very much so

c. Somewhat

b. For the most part

d. Only slightly

c. Somewhat

e. Not at all

d. Only slightly
e. Not at all

5. In the last 3 months, this social worker has asked
me about supports and services that my family
needs.

9. In the last 3 months, this social worker has been
honest.

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

6. In the last 3 months, this social worker has tried to
learn about my family's values, beliefs, culture and
traditions.

10. In the last 3 months, this social worker has been
respectful.
a. Very much so

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

11. In the last 3 months, this social worker has made an
effort to understand the grief and pain my family is
feeling as a result of my child being placed in foster
care.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all

Draft

Section B
These questions ask you about the people in your life, such as family members and other people in your community or tribe
who work closely with you and support you during your Child Welfare Services case. These are people other than your Child
Welfare Services social worker or other child welfare staff. Your social worker may sometimes call this group of people your
"circle of support." Please think about the people who have played an important role in helping and supporting your family
during your involvement with Child Welfare Services over the past 3 months.
12a. Please indicate whether each person below has been helping you by marking Yes, No, or NA. Mark N/A
(Not Applicable/Does not apply) if the person is deceased; or you don't have a brother, a sister, etc.; or if
the person is not in your life.

Person Category

12a. Is this person a part of your circle of support?
Yes

N/A

Your mother
Your father
Your sister(s)
Your brother(s)
Your grandparent(s)
Your adult child(ren)
Your cousin(s)
Your stepmother
Your stepfather
Your aunt(s)
Your uncle(s)
Your friend(s)
Your neighbor(s)/co-worker(s)
Your child's father/mother
The family of your child's
father/mother
Your child's teacher
Your counselor(s) or therapist(s)
Spiritual leader/advisor,
minister, pastor or priest
Elder(s), leader(s), member(s)
of your community or tribe

Draft

12b. Which 3-5 persons in your circle of support have been the most helpful to your family during your
involvement with Child Welfare Services over the past 3 months? (You may mark up to 5 boxes below.)
Relationship Codes
1. Your mother

8. Your stepmother

14. Your child's father/mother

2. Your father

9. Your stepfather

15. The family of your child's
father/mother

3. Your sister(s)

10. Your aunt(s)

16. Your child's teacher

4. Your brother(s)

11. Your uncle(s)

17. Your counselor(s) or
therapist(s)

5. Your grandparent(s)

12. Your friend(s)

18. Spiritual leader/advisor,
minister, pastor or priest

6. Your adult child(ren)

13. Your neighbor(s)/
co-worker(s)

19. Elder(s), leader(s), member(s)
of your community or tribe

7. Your cousin(s)

Draft

15. In the last 3 months, my circle of support and I
have worked as a team to develop services and
supports that respect my family's way of life, our
preferences, and our priorities.

13. In the last 3 months, my circle of support and I
have worked together to find solutions to the
problems my family is facing.
a. Very much so
b. For the most part

a. Very much so

c. Somewhat

b. For the most part

d. Only slightly

c. Somewhat

e. Not at all

d. Only slightly
e. Not at all

14. In the last 3 months, my circle of support has
helped me do what I need to do to bring my child
home and to close my family's case.

16. In the last 3 months, when I'm in meetings with
Child Welfare Services about my child, my circle of
support and I have had the opportunity to express
our goals for my family.

a. Very much so
b. For the most part

a. Very much so

c. Somewhat

b. For the most part

d. Only slightly

c. Somewhat

e. Not at all

d. Only slightly
e. Not at all

Section C
These questions ask about how you feel about your family's future in relation to your child coming home. Think about the
child involved with Child Welfare Services that you identified at the beginning of the questionnaire when you answer these
questions. Please
your response.
17. In the last 3 months, I have gotten the support I
needed to help me with my feelings in this
situation.

19. I believe I can influence the decisions that are being
made about my child's future.
a. Very much so

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

20. I believe that my child will have family and other
loving relationships to support him/her through
his/her life.

18. In the last 3 months, my child has gotten the
support he/she needed to deal with his/her feelings
about this situation.

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

Draft

21. I believe that my child will be able to live safely
with me without Child Welfare Services being
involved.
a. Yes

a. Very much so

 CONTINUE TO QUESTION #22

b. Maybe
c. No

24. I believe I can count on myself to manage things
well at home when my child comes home.



b. For the most part

 CONTINUE TO QUESTION #22

c. Somewhat

SKIP TO QUESTION #26

d. Only slightly
e. Not at all

22. I believe that friends and family will give me the
help and support that I need to care for my child
at home.

25. I believe I can make plans for my family's future and
take steps to make those plans come true.

a. Very much so

b. For the most part

c. Somewhat

d. Only slightly

e. Not at all

23. I believe I can handle most of the difficulties I
might face in caring for my child when he/she
comes home.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all

Section D
Case Activities with Family and Friends
You may have children involved in Child Welfare Services other than the child you named at the beginning of the
questionnaire. Please answer these next questions about any of your children.
26. I have told my social worker about family or
friends who may be able to help my child(ren) and
me reunite and stay together as a family.

28. The family or friends that I have identified have
participated with me in one or more team
meetings with my social worker.

 CONTINUE TO QUESTION #27
No  SKIP TO QUESTION #29

a. Yes

b. No

27. These family members or friends are helping my
child(ren) and me reunite and stay together as a
family.
a. Yes
b. No

Draft

29. Case Activities with Community Representatives
In the questions below, Community and Tribal
representatives include the following:
• Teachers
• Counselors or therapists
• Spiritual or Church leaders or advisors, such as
ministers pastors or priests
• Other community leaders or elders
• Other tribal representatives

33. I have taken steps to change my behavior so my
child(ren) can be safe in my care.
a. Yes
b. No
34. My social worker and I have talked about how I
am changing my behavior so my child(ren) can be
safe in my care.
a. Yes

29a. I have told my social worker about Community or
Tribal representatives who are important to my
child(ren) or our family.

b. No
35. I have completed one or more supervised
visitations with one or more of my child(ren).

 CONTINUE TO QUESTION #30
No  SKIP TO QUESTION #32

a. Yes
b.

a. Yes
b. No

30. Community or Tribal representatives are helping
my child(ren) and me reunite and stay together as
a family.

c. I have not been cleared for visitation with
my child(ren).
36. I have completed one or more unsupervised
visitations with one or more of my child(ren).

a. Yes
b. No

a. Yes

31. Community or Tribal representatives have
participated with me in one or more team
meetings with my social worker.

b. No
c. I have not been cleared for visitation with
my child(ren).

a. Yes

37. I have completed one or more overnight
visitations with one or more of my child(ren).

b. No
Case Activities with You

a. Yes

32. With my social worker, I have identified ways to
change my behavior so my child(ren) can be safe
in my care.

b. No
c. I have not been cleared for visitation with
my child(ren).

a. Yes
b. No

Draft

Section E
38. How many children do you currently have involved
with Child Welfare Services?

42. What is your relationship to this child?
a. Biological mother or father
b. Adoptive mother or father

Number of children

c. Relative guardian
Please specify:

39. Thinking about the child named at the beginning
of the survey, what is this child's gender?
a. Male

d. Non-relative guardian
Please specify:

b. Female
40. What is this child's date of birth?

Month

43. What is your gender?

Day

a. Male

Year

b. Female

41a. Is this child Hispanic, Latino, or Spanish?

44. What is your age?

a. Yes
b. No

years

41b. What is this child's race?
(Please mark one or more)

45a. Are you Hispanic, Latino, or Spanish?

a. American Indian

a. Yes

b. Alaska Native

b. No

c. Asian

45b. What is your race?
(Please mark one or more)

d. Black or African American
e. Native Hawaiian or Other Pacific Islander

a. American Indian

f. White

b. Alaska Native

g. Other
Please specify:

c. Asian
d. Black or African American
e. Native Hawaiian or Other Pacific Islander
f. White
g. Other
Please specify:

You have reached the end of the questionnaire.
Have you: _____ Completed all sections of the questionnaire?
_____ Signed the Informed Consent?
_____ Included a mailing address for the incentive?
Please place this survey in the pre-paid envelope and place in any United States
Postal Service mailbox.
Thank you for participating.
Draft

File Type	application/pdf
File Modified	2015-10-06
File Created	2015-10-06