Attachment 2A-9: Caregiver Informed Consent and Questionnaire Telephone 10-15
CAPP Caregiver Informed Consent – Telephone
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 completing this telephone survey.
If you agree to participate, 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.
Before I go on, I need to let you know that I am taping this phone call so I can record if you want to take part or not.
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.
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 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 in the survey.
I would like to participate in the study, but I have questions. Who can I contact?
I can answer questions for you. If you have any questions about the study after we complete the questionnaire, 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 that was previously mailed to you.
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
Do you agree that you have received a copy of the Research Participant’s Bill of Rights, and will take part in the telephone survey?
Yes No
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:
Be told the nature and purpose of the study.
Be given an explanation of what will happen during the study and of how the research participant is expected to participate.
Be given an explanation of any risks or discomforts that may be experienced as a result of participating in the study.
Be given an explanation of any benefits that may be expected from participation in the study.
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.
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.
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.
Be told that you may refuse to answer any question.
Be given a copy of the signed and dated consent form.
Be free of pressure when considering whether to consent to, and participate in, the study.
Be informed, upon request, about the results of the study.
CAPP Caregiver Questionnaire
INTERVIEWER: 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 (insert County and/or Office Name here) Child Welfare Services who has been working with the child. There is a sticker on your survey with a social worker’s name and a child’s name. Can you please tell me . . .
What is the name of the social worker? __________________________________________
What is the name of the child? __________________________________________________
Please think about these two individuals 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.
You can ask me questions at any time if you don’t understand something and you can skip questions that you do not want to answer. There are no right and wrong answers. Please think carefully about each question and answer them to the best of your ability.
Section A
INTERVIEWER: Please think about your experiences with the social worker you named at the beginning of the questionnaire, and your response to the following statements. For each statement, there are five response options. I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
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
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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
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.
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 I think the child needs.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
5. In the last 3 months, this social worker has asked me about supports and services that I think our family needs.
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 the values, beliefs, culture and traditions of the child and our family.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
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
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
d. Only slightly
e. Not at all
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
10. In the last 3 months, this social worker has been respectful.
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 the child may be feeling as a result of being placed in foster care.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
Section B
INTERVIEWER: 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. INTERVIEWER: I would like to make a list of who you consider to be in this circle of support. First, I will name a person that could potentially be in the circle. Please indicate Yes or No if that person has been in the circle of support for the child and your family over the past 3 months. You can say Not Applicable if the person is deceased; the relationship doesn’t exist (for example, you don’t have a brother or a sister); or if the person is not in your life.
Person Category |
13a. Is this person a part of your circle of support? |
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Your mother |
Yes |
No |
N/A |
Your father |
Yes |
No |
N/A |
Your sisters (s) |
Yes |
No |
N/A |
Your brother(s) |
Yes |
No |
N/A |
Your grandparent(s) |
Yes |
No |
N/A |
Your adult child(ren) |
Yes |
No |
N/A |
Your cousin(s) |
Yes |
No |
N/A |
Your stepmother |
Yes |
No |
N/A |
Your stepfather |
Yes |
No |
N/A |
Your aunt(s) |
Yes |
No |
N/A |
Your uncle(s) |
Yes |
No |
N/A |
Your friend(s) |
Yes |
No |
N/A |
Your neighbor(s)/co-worker(s) |
Yes |
No |
N/A |
The child’s father/mother |
Yes |
No |
N/A |
The family of the child’s father/mother |
Yes |
No |
N/A |
The child’s teacher |
Yes |
No |
N/A |
The child’s counselor(s) or therapist(s) |
Yes |
No |
N/A |
Spiritual leader/advisor, minister, pastor or priest |
Yes |
No |
N/A |
Elder(s), leader(s), member(s) of the community or tribe |
Yes |
No |
N/A |
13b. INTERVIEWER: I would now like to figure out 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. I will name several options, and you can indicate up to 5 persons who have been most helpful. NOTE: Interviewer may skip options where the respondent indicated N/A in Question 13a.
Relationship Codes |
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INTERVIEWER: Thank you. I will now ask some questions about how you have worked with the circle of support. For each statement, there are five response options. I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
15. In the last 3 months, the child’s circle of support has helped me to do what I need to support permanency for the child.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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
c. Somewhat
d. Only slightly
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
e. Not at all
Section C
INTERVIEWER: These questions ask about how you feel about your family’s future in relation to your child in your care. Please think about the child involved with Child Welfare Services that was named at the beginning of the questionnaire when you answer these questions. For each statement, there are five response options. I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
19. In the last 3 months, I have gotten the support I needed to help me with my feelings in caring for this child.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
23. I feel I can influence the decisions that are being made about this child’s future.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
INTERVIEWER: The response options for this next question are Yes, Maybe, or No.
24. I believe that in the future this child will live permanently in my family without Child Welfare Services being involved.
a. Yes – CONTINUE TO QUESTION #25
b. Maybe – CONTINUE TO QUESTION #25
c. No – SKIP TO QUESTION #28
INTERVIEWER: The response options for these next questions go back to five. For each statement, I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
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
b. For the most part
c. Somewhat
d. Only slightly
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
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.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
Section D
INTERVIEWER: These questions are about activities that you and other important people participate in with the social worker and child involved with Child Welfare Services identified at the beginning of the questionnaire. Please answer Yes or No to the following questions.
29. I have participated in one or more team meetings with this social worker about this child.
a. Yes
b. No
30. I have told this social worker about people who are important sources of support for this child and our family.
a. Yes
b. No
31. The people I identified as important sources of support are helping our family care for and support this child.
a. Yes
b. No
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
b. No
Section E
INTERVIEWER: This is the final portion of the questionnaire. These last questions ask for some general information about you and the child in your care. The response options are different for each question, so I will review the response options for each one as I ask the question.
33. Which best describes your caregiving relationship to this child?
a. Relative Caregiver
b. Non-Relative Extended Family Member Caregiver
c. County Licensed Foster Parent
d. Foster Family Agency Foster Parent
e, Other (please specify: ____________________)
34a. Is this child Hispanic, Latino, or Spanish?
a. Yes
b. No
34b. What is this child’s race? (Please chose one or more)
a. American Indian
b. Alaska Native
c. Asian
d. Black or African American
e. Native Hawaiian or Other Pacific Islander
f. White
g. Other, please specify: _______________________
35. How many children do you currently have placed with you who are involved with Child Welfare Services? _____
36. What is your gender?
a. Male
b. Female
37. What is your age? _____ years
38a. Are you Hispanic, Latino, or Spanish?
a. Yes
b. No
38b. What is your race? (Please chose one or more)
a. American Indian
b. Alaska Native
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.
Thank you for participating.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | cyrstacer |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |