(K.1) Head Start parent consent form for Plus study (AI/AN FACES)

AI/AN FACES CONSENT FORM

We invite you and your child to take part in the American Indian and Alaska Native (AI/AN) Head Start Family and Child Experiences Survey, known as AI/AN FACES. AI/AN FACES is the first national study to collect information about the characteristics and experiences of children and families served by Head Start programs in American Indian and Alaska Native communities. The study will help us learn more about children and families in AI/AN Head Start programs and the services Head Start provides. It will allow Head Start to better serve the needs of children and families in tribal Head Start programs. We are inviting you and your child to participate because your child attends a Head Start program included in the AI/AN FACES Study. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is paying for AI/AN FACES. Mathematica Policy Research, an independent firm, is conducting the study.

If you agree to take part…

We will ask you to fill out two surveys, one this fall and one in spring 2016. You can choose to fill out the survey online or by phone. We will ask you about your child, your family’s activities and routines such as eating meals together, your feelings, and your health. The surveys will take about 30 minutes each. If you want to fill out the survey online but do not have internet access, you can fill it out online at your child’s Head Start center during the week the AI/AN FACES data collection team is visiting. Computers will be available for you to use.

We will conduct a FACES child assessment with your child this fall and in spring 2016 so we can find out how Head Start helps children learn and grow. During the FACES child assessment, we will ask your child to do some fun activities with a trained member of our study team. For example, we will ask your child to look at pictures, copy drawings, and answer simple math questions. This will take about 45 minutes.

You will receive a debit gift card and your child will receive a book. After you finish your survey this fall and spring 2016, we will send you a $15 pre-paid debit gift card. If you fill out the survey within two weeks of being asked to do so, you will receive an additional $5. If you fill out the survey online, you will receive an additional $5. Therefore, if you do the survey online within the first two weeks, you could receive a total of $25. After your child finishes the FACES assessment, 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. Your child’s teacher will fill out a brief survey with questions about your child’s behavior, skills, and any special concerns or disabilities. Your child’s classroom will be observed by a trained member of the study team once in spring 2016 so that we can learn more about how Head Start teachers work with the children in their classrooms.

You can choose whether you and your child will be part of the study. Taking part is completely voluntary. Your choice to take part or not will not affect the Head Start services you and your child receive. If you choose to take part in the study but then decide you want to leave the study at any point, that is okay.

We will protect your privacy. No one from Head Start will see or hear your answers to the questions in the parent survey or learn about how your child does on the FACES child assessment. We will only report study results for parents, children, and programs as a group. All information collected as part of AI/AN FACES will be kept private unless we learn that a child has been hurt or is in danger or you tell us that you plan to seriously hurt yourself or someone else – then by law, we must make a report to the appropriate legal authorities.

To help us protect the privacy of study participants, we have a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, we cannot be forced to share information that may identify any study participants, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. More information about the Certificate is provided at the end of this consent form.

If you have questions about AI/AN FACES, please call Felicia Parks of Mathematica Policy Research, toll free at 844-807-6007. If you have questions about your rights as a study volunteer, please call the New England Institutional Review Board toll free at 1-800-233-9570. You can find out more about AI/AN FACES on the study website at 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 if you would like to take part. 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 AI/AN FACES study staff collect some information from my child’s Head Start teacher about my child’s behavior, skills, and any special concerns or disabilities. I also agree to take part in the study by filling out a survey. I will receive a $15 pre-paid debit gift card after I fill out the survey in the fall, and again after I fill out the survey in the spring. If I finish a survey within two weeks of being asked to do so, I will receive an additional $5. If I fill out a survey online, I will also receive an additional $5. Therefore, if I fill out the survey online within the first two weeks, I will receive a total of $25 in the form of a pre-paid debit gift card. My child will also receive a children’s book each time he or she is assessed by the study team. I can 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. Address :

Address 1 Address 2

City State Zip

8. Email address

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

 Yes  No

10. Child’s gender  Male  Female

11. Child’s birthday

Month Day Year

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

 English Tribal language ________________  Spanish  Other _______________

* In case you would like to fill out 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/2018. 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.

Certificate of Confidentiality

AI/AN FACES researchers will use the Certificate to resist any demands for information that would identify study participants, with one exception. The Certificate of Confidentiality does not prevent the AI/AN FACES study team from disclosing information that would identify participants in the research project if participants were to tell the researchers or interviewers anything that suggests they are very likely to harm themselves, that they are planning to hurt another person or child, or that someone is likely to harm them.

The Certificate of Confidentiality does not prevent study participants from voluntarily releasing information about themselves or their involvement in this study. If an insurer, employer, or other person obtains a study participant’s written consent to receive research information, then the researchers may not use the Certificate to withhold that information. Further, the U.S. Department of Health and Human Services (DHHS) may ask for data for an audit or evaluation. If they do, we will need to provide it. However, only DHHS staff involved in the review will see it.