CAPP Caregiver Questionnaire

CAPP Caregiver 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 the children in your care. One of the ways you can help us learn to
better serve you and the children in your care 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 the children in your
care.
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 one
of the cases of a child in your care.
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.

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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.

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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.

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CAPP Caregiver 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 a child in your care
who is involved in Child Welfare Services, sometimes called "CPS", and the social worker at <> who has been
working with the child. They are named below.

PII-ET to insert sticker here with
social worker name and child
first name and last initial.

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

Section A
Please think about your experiences with the social worker named at the beginning of the questionnaire, and your response
to the following statements. Please
your response.
3. In the last 3 months, this social worker has asked
about relatives and other people in the life of the
child and our family who might be helpful to the
child and our family.

1. In the last 3 months, this social worker has taken
the time to listen to things I have to share about
this child.
a. Very much so

a. Very much so

b. For the most part

b. For the most part

c. Somewhat

c. Somewhat

d. Only slightly

d. Only slightly

e. Not at all

e. Not at all

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

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

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
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-E

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CAPP Caregiver_IRB draft_ v6

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

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

a. Very much so

b. For the most part

b. For the most part

c. Somewhat

c. Somewhat

d. Only slightly

d. Only slightly

e. Not at all

e. Not at all

10. In the last 3 months, this social worker has been
respectful.

6. In the last 3 months, this social worker has tried to
learn about the values, beliefs, culture and
traditions of the child and 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

11. In the last 3 months, this social worker has made an
effort to understand the grief and pain the child may
be feeling as a result of being placed in foster care.

e. Not at all
7. In the last 3 months, this social worker has
respected the values, beliefs, culture and traditions
of the child and our family when making decisions
about supports and services for us.

a. Very much so
b. For the most part
c. Somewhat

a. Very much so

d. Only slightly

b. For the most part

e. Not at all

c. Somewhat

12. In the last 3 months, this social worker has made an
effort to understand how the grief and pain this
child may be feeling is affecting our family.

d. Only slightly
e. Not at all
8. In the last 3 months, this social worker has tried to
understand the things that have had a major impact
on the child and our family.

a. Very much so
b. For the most part
c. Somewhat

a. Very much so

d. Only slightly

b. For the most part

e. Not at all

c. Somewhat
d. Only slightly
e. Not at all

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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 and the child during the Child Welfare Services case. These are people other than
the Child Welfare Services social worker or other child welfare staff. The social worker may sometimes call this group of
people a "circle of support." Please think about the people who have played an important role in helping and supporting the
child and your family during the child's involvement with Child Welfare Services over the past 3 months.
13a. Please indicate whether each person below has been helping the child and your family 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

13a. Is this person a part of your circle of support?
Yes

No

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)
The child's father/mother
The family of the child's
father/mother
The child's teacher
The child's counselor(s) or
therapist(s)
Spiritual leader/advisor,
minister, pastor or priest
Elder(s), leader(s), member(s)
of your community or tribe

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13b. Which 3-5 persons in your circle of support have been the most helpful to the child and 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. Child's father/mother

2. Your father

9. Your stepfather

15. Family of child's
father/mother

3. Your sister(s)

10. Your aunt(s)

16. Child's teacher

4. Your brother(s)

11. Your uncle(s)

17. Child's 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)

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14. In the last 3 months, the child's circle of support
and I have worked together to find solutions to the
problems that the child and our family have faced.

17. In the last 3 months, the child's circle of support
and I have worked as a team to develop services
and supports for our family that are respectful of
our family's way of life, our preferences and our
priorities.

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

15. In the last 3 months, the child's circle of support
has helped me do what I need to support
permanency for the child.

e. Not at all
18. In the last 3 months, when I'm in meetings with
Child Welfare Services about the child, the
child's circle of support and I have had the
opportunity to express our goals for the child
and our family.

a. Very much so
b. For the most part
c. Somewhat
d. Only slightly

a. Very much so

e. Not at all

b. For the most part
c. Somewhat

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

d. Only slightly
e. Not at all

a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all

Section C
These questions ask about how you feel about your family’s future in relation to the child in your care. Think about the child
involved with Child Welfare Services that was named at the beginning of the questionnaire when you answer these
questions. Please
your response.
19. In the last 3 months, I have gotten the support I
needed to help me with my feelings in caring for
this child.

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

a. Very much so

a. Very much so

b. For the most part

b. For the most part

c. Somewhat

c. Somewhat

d. Only slightly

d. Only slightly

e. Not at all

e. Not at all

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

25. I believe that friends and family will give the help
and support needed for this child to be a
permanent part of our family.

a. Very much so

a. Very much so

b. For the most part

b. For the most part

c. Somewhat

c. Somewhat

d. Only slightly

d. Only slightly

e. Not at all

e. Not at all
26. I believe our family can handle most of the
difficulties we might face in caring for this child
as a permanent member of our family.

22. I believe that this child will have family and other
loving relationships to support him/her through
his/her life.
a. Very much so

a. Very much so

b. For the most part

b. For the most part

c. Somewhat

c. Somewhat

d. Only slightly

d. Only slightly

e. Not at all

e. Not at all
27. I feel I can make plans for the future of this child
and our family and take steps to make those
plans come true.

23. I feel I can influence the decisions that are being
made about this child’s future.
a. Very much so

a. Very much so

b. For the most part

b. For the most part

c. Somewhat

c. Somewhat

d. Only slightly

d. Only slightly

e. Not at all

e. Not at all

24. I believe that in the future this child will live
permanently in my family without Child Welfare
Services being involved.

If you answered Questions 25-27, skip to Question #29.
28. I believe that in the future this child will be able
to live permanently in a family without Child
Welfare Services being involved.

 CONTINUE TO QUESTION #25
b. Maybe  CONTINUE TO QUESTION #25
c. No  SKIP TO QUESTION #28
a. Yes

a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all

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Section D
These questions are about activities that you and other important people participate in with the social worker and child
involved with Child Welfare Services from page 1 of the questionnaire. Please answer yes or no to the following questions:
31. The people I identified as important sources of
support are helping our family care for and
support this child.

29. I have participated in one or more team meetings
with this social worker about this child.
a. Yes

a. Yes

b. No

b. No

30. I have told this social worker about people who
are important sources of support for this child and
our family.

32. The people I have identified as important sources
of support have participated with me in one or
more team meetings with this social worker.

a. Yes

a. Yes

b. No

b. No

Section E
33. Which best describes your caregiving relationship
to this child?

35. How many children do you currently have placed
with you who are involved with Child Welfare
Services?

a. Relative Caregiver
b. Non-Relative Extended Family Member Caregiver

Number of children

c. County Licensed Foster Parent
d. Foster Family Agency Foster Parent

36. What is your gender?

e. Other
Please specify:

a. Male
b. Female
37. What is your age?

34a. Is this child Hispanic, Latino, or Spanish?

years

a. Yes

38a. Are you Hispanic, Latino, or Spanish?

b. No

a. Yes

34b. What is this child's race?
(Please mark one or more)

b. No

a. American Indian

38b. What is your race?
(Please mark one or more)

b. Alaska Native
c. Asian

a. American Indian

d. Black or African American

b. Alaska Native

e. Native Hawaiian or Other Pacific Islander

c. Asian

f. White

d. Black or African American

g. Other
Please specify:

e. Native Hawaiian or Other Pacific Islander
f. White
g. Other
Please specify:

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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

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