Family Screening and Consent

Mother and Infant Home Visiting Program Evaluation (MIHOPE)

05_MIHOPE Consent for All Respondent Activities 7 10 12

Family Screening and Consent

OMB: 0970-0402

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OMB Control No: 0970 -0402

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ATTACHMENT 5: MIHOPE CONSENT FOR ALL RESPONDENT ACTIVITIES

7/10/2012

Agreement to Take Part in the Mother and Infant Childhood

Home Visiting Program Evaluation

We would like you to take part in an important research project about the effects of home visiting services. The project is funded by the US Department of Health and Human Services. MDRC is running the study with Mathematica Policy Research and other researchers. The study will provide information to help improve services for parents with young children.

WHAT DOES IT MEAN TO BE IN THE STUDY?

About 5,100 families will be in the study around the country. Half the families in the study will be offered home visiting services. The other half will receive information about other services in the community. You will have the same chance to get home visiting services as everyone else. Picking the families who will be offered home visiting services will be done randomly, like tossing a coin.

If you agree to take part in the study, we will ask you to do the following:

Agree to be interviewed by telephone for about an hour today or at a convenient time.

We will want to talk to you about you and your family. We will ask about your health, feelings, use of social services, and what you hope to get from the home visiting program. We will also ask about your relationships and background. You will receive $25 for completing the interview.

We will ask you to tell us how we can reach you in the future. We may ask you for the names of people who will know how to reach you.

Allow someone from the study team to observe your home environment and take notes.

Agree to be interviewed in the future when your baby is about 15 months old.

We will ask about you and your child. You will receive $25 for completing each interview. You may refuse to answer any of the questions.

We will send you a postcard so you can tell us how to reach you. You will receive a $5 gift certificate for returning the postcard.

Allow us to obtain information from home visiting programs.

If you are chosen to receive home visiting services, we will ask the program about the services you receive. This will include how often you see the home visitor and what you discuss with the home visitor. We will also ask other home visiting programs in your community about your use of their services.

Allow us to obtain information on health and social service programs that your family uses.

This might include information from your child’s birth certificate and from the Child Protective Service system. It might include information on benefits such as Medicaid, cash assistance, and food stamps. It might include information from your child’s school after your child starts going to school, and information from you and your child’s health care providers. We will need you to give us your Social Security number to get this information. We may also use your Social Security number to help locate you when we want to talk to you in the future.

RISKS AND BENEFITS

Taking part in the study will help improve services for parents with young children. You will receive $25 for completing the interview today.

There are some risks to being in the study. Some of the questions involve sensitive topics and may be stressful to answer. There is a small risk that your information will be seen outside the study team. However, the study team follows strict rules to protect your privacy. We will keep your information private unless there is concern that you or someone else may be harmed. No reports will include your name or other identifying information.

BEING PART OF THE STUDY IS YOUR CHOICE

Taking part in the study is your choice. If you decide not to be in the study, there is no penalty. Your decision will not affect whether you are given a spot in the home visiting program. Only half of families will be able to receive home visiting services. If you are not selected for the home visiting program, you can use other services in your community.

You may stop participating in the study at any time. You may refuse to answer any questions we ask, both today and in the future. You do not have to give us your Social Security number if you do not want to. You will not lose any benefits or services to which you would be otherwise entitled.

INFORMATION WILL BE PRIVATE

The research team follows strict rules to keep your information private. All study staff are trained to protect privacy. All study staff sign a confidentiality pledge. The study has a Certificate of Confidentiality from the U.S. government. This certificate states that we do not have to identify you, even under a court order or subpoena. However, if keeping your answers private would put you or someone else in serious danger, we will have to tell the appropriate agencies to protect you or the other person. In addition, the government may see your information if it audits the study, but it would keep your information confidential.

All information about you will be marked with a code number, not your name. No reports will describe you in a way that would allow you to be identified. We have to deliver the study data to the federal government at the end of the study, but the data file will not contain information that could be used to identify you.

If you have questions at any time, please call MDRC toll-free at 1-877-311-6372.

Participant’s Statement:

“The research procedures, risks and benefits have been explained to me. I recognize that I am free to ask any questions. I understand that taking part in this study is my choice. I understand that being in the study will not affect any benefits that I or members of my family receive, now or in the future. I understand that I am free to stop taking part in the study at any time. I understand that I can refuse to answer any questions in the interviews. I understand that any information that can be used to identify me will be kept private, unless there is concern that I or someone else may be harmed.

I agree to provide contact information so that I can be interviewed in the future. I agree that the research team may obtain information from the state or federal government, from home visiting programs, and from my family’s health care providers.”

Agreement to participate in the study:

Print Name ____________________________

_________________________________ _____________

Signature Date

Assent for Unemancipated Minors to Take Part in the Mother and Infant Childhood Home Visiting Program Evaluation

WHAT DOES IT MEAN TO BE IN THE STUDY?

If you agree to take part in the study, we will ask you to do the following:

Agree to be interviewed by telephone for about an hour today or at a convenient time.

We will want to talk to you about you and your family. We will ask about your health, feelings, use of social services, and what you hope to get from the home visiting program. We will also ask about your relationships and background. You will receive $25 for completing the interview.

We will ask you to tell us how we can reach you in the future. We may ask you for the names of people who will know how to reach you.

Allow someone from the study team to observe your home environment and take notes.

Agree to be interviewed in the future when your baby is about 15 months old.

We will ask about you and your child. You will receive $25 for completing each interview. You may refuse to answer any of the questions.

We will send you a postcard so you can tell us how to reach you. You will receive a $5 gift certificate for returning the postcard.

Allow us to obtain information from home visiting programs.

If you are chosen to receive home visiting services, we will ask the program about the services you receive. This will include how often you see the home visitor and what you discuss with the home visitor. We will also ask other home visiting programs in your community about your use of their services.

Allow us to obtain information on health and social service programs that your family uses.

This might include information from your child’s birth certificate and from the Child Protective Service system. It might include information on benefits such as Medicaid, cash assistance, and food stamps. It might include information from your child’s school after your child starts going to school, and information from you and your child’s health care providers. We will need you to give us your Social Security number to get this information. We may also use your Social Security number to help locate you when we want to talk to you in the future.

Allow us to ask a parent or guardian to provide consent for you to be in the study.

Because you are a minor, we must get permission from a parent or guardian for you to be in the study. We will not share any information about you with your parent or guardian.

RISKS AND BENEFITS

Taking part in the study will help improve services for parents with young children. You will receive $25 for completing the interview today.

BEING PART OF THE STUDY IS YOUR CHOICE

INFORMATION WILL BE PRIVATE

If you have questions at any time, please call MDRC toll-free at 1-877-311-6372.

Participant’s Statement:

“The research procedures, risks and benefits have been explained to me. I recognize that I am free to ask any questions. I understand that taking part in this study is my choice. I understand that being in the study will not affect any benefits that I or members of my family receive, now or in the future. I understand that I am free to stop taking part in the study at any time. I understand that I can refuse to answer any questions in the interviews. I understand that any information that can be used to identify me will be private, unless there is concern that I or someone else may be harmed.

Agreement to participate in the study:

Print Name ____________________________

_________________________________ _____________

Signature Date

Agreement to be Video-Recorded for the Mother and Infant Childhood

Home Visiting Program Evaluation

Thank you for agreeing to take part in the Mother and Infant Home Visiting Program Evaluation (MIHOPE). As you were told, this is a research project about the effects of home visiting services. The project is being funded by the US Department of Health and Human Services. MDRC is conducting the study with Mathematica Policy Research and other researchers. The study will help improve services for parents with young children.

We are thankful for your time and help in MIHOPE. We would like you to help us in one more way. We would like to video record your interaction with the home visitor at two times in the future. The video recordings will give us information on what happens during the visits. The video recordings are also valuable teaching tools. We would like your permission to use the video records for research and research training purposes.

WHAT DOES IT MEAN TO BE VIDEO-RECORDED?

The study team would like to record a typical visit at two times in the future. You do not need to change anything you do in meeting with the home visitor. The study team member doing the recording will try to remain out of your way. If you agree to be recorded, the study team will call you to schedule the recording.

RISKS AND BENEFITS

The recordings will help improve services for parents with young children. You will receive $20 each time you are video recorded. We will also give you a small gift for your child.

There may be a small risk that your video will be seen outside the research team. However, the study team follows strict rules to protect the confidentiality of your information. We will keep your information confidential unless there is concern that you or someone else may be harmed. No reports will include your name or other identifying information. The information you give us will not be provided to government agencies in a way that could identify you.

BEING VIDEO-RECORDED IS YOUR CHOICE

Being video-recorded is your choice. If you decide not to be recorded, there is no penalty.

INFORMATION WILL BE PRIVATE

The research team follows strict rules to keep your information private. All study staff are trained to protect confidentiality. All study staff sign a confidentiality pledge. The study has a Confidentiality Certificate from the U.S. government. This states that we do not have to identify you, even under a court order or subpoena. If the video-recording indicates that you or someone else in serious danger, then we will have to tell the appropriate agencies to protect you or the other person. In addition, the government may see your information if it audits the study, but it would keep your information confidential.

No reports will describe you in a way that would allow you to be identified.

If you have questions at any time, please call at MDRC toll-free at 1-877-311-6372.

Participant’s Statement:

“I agree to have my image and voice recorded for the MIHOPE project. This video will show what happens when my children and I meet with the home visitor. This video will not be sold. It will not be used for commercial purposes.

I understand that only the image and voice of my children and me as they appear during the interaction with the home visitor will be revealed. I understand that I do not have to participate in the video. I understand that I can have the recording stopped at any time.”

Print Name ____________________________

_________________________________ _____________

Signature Date

MIHOPE Protocol for Consenting Minors

A small number of study participants will likely be minors. What constitutes a minor and the rules of emancipation for minors differ by state. We will develop a list of the rules governing minors and emancipation of minors for each state included in our study once states have been recruited. The list of rules will be included in the field staff training materials and discussed during training.

If a state requires parental consent, then Mathematica field staff will contact the minor to obtain written assent using the same procedures for obtaining consent from other study participants. If the minor provides assent, Mathematica staff would contact the minor’s parent or guardian by telephone to obtain oral consent for their child’s participation in the study. This oral consent will be documented. If the parent or guardian does not grant consent, we will document the refusal. The case will be recorded as a final refusal by parent.

If the state does not require parental consent, Mathematica will contact the minor and attempt to recruit him or her into the study, as would be done for other potential study participants.

Home visitors will gather information on eligible minors when determining study eligibility, such as the participant’s date of birth, and the parents or guardians’ names and contact information.

A script and set of frequently asked questions to be used with parents of minors begins on the next page.

MIHOPE SCRIPT FOR PARENTAL CONSENT OF MINORS

ELLO. My name is __________________ from Mathematica Policy Research. May I speak with [PARENT NAME]?

SPEAKING TO [PARENT NAME] 1 GO TO parentname

[PARENT NAME] COMES TO THE PHONE 2 GO TO parentname

PARENTNAME.

Good (morning/afternoon/evening). My name is __________________, and I’m calling from Mathematica Policy Research. We are conducting a study for the U.S. Department of Health and Human Services to learn about home visiting programs and the different kinds of services these programs provide to children and families. Your daughter, (NAME), is eligible to participate in this study and we are contacting you to request your consent as her parent or guardian since she is a minor.

The purpose of the study is to learn more about families who enroll in home visiting programs and how those programs provide different kinds of services to children and families. About 5,100 families in total will be in the study around the country.

Her participation involves 4 main things:

being interviewed by telephone for about an hour at a convenient time during the next couple of weeks;
being interviewed again in the future, when her child is 15 months old;
giving permission to obtain information from state and federal government agencies about your daughter and her child;
giving permission to video-tape up to two home visits with your daughter’s home visitor to learn about the kinds of things home visitors talk about and do with clients; and

Your daughter can refuse to answer any question on the interviews. She can also refuse to be videotaped with the home visitor.

Your daughter’s participation is voluntary. If she does not participate in the study, there is no penalty.

Do you have any questions about the study or (NAME)’s participation in it?

YES 1 GOT TO FAQ

NO 0

DON’T KNOW d

REFUSED r

Do you consent to allow (NAME) to participate in the study?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Thanks very much. Have a nice day. END CALL.

FREQUENTLY ASKED QUESTIONS (FAQ)

Q: WHAT KIND OF QUESTIONS WILL BE ASKED DURING THE INTERVIEW?

We will want to talk to her about herself and her child. We will ask her questions about her health, feelings, use of social services, and what she hopes to get from the home visiting program. We will also ask her some questions about her relationships and background. She will receive $25 for completing the interview.

Q: WHAT KIND OF INFORMATION WILL BE GATHERED FROM FEDERAL AND STATE AGENCIES?

This could include information from your daughter’s child’s birth certificate, from the Child Protective Service system, and on benefits such as Medicaid, cash assistance, and food stamps. We will ask her to give us her Social Security number to get information from state systems.

Q: WHAT ARE THE RISKS AND BENEFITS OF PARTICIPATION?

Some of the questions we ask involve sensitive topics and they may be stressful to answer. She may refuse to answer any questions, both for the initial interview and for the future interview. There may be a small risk because she is sharing confidential information with us. However, the study team follows strict rules to protect participant confidentiality and we will keep her information confidential. No reports will include her name or other identifying information. The information she gives us will not be provided to government agencies in a way that could identify her. All participants will receive $25 for completing the interview.

Q: DOES MY DAUGHTER HAVE TO TAKE PART IN THE STUDY?

Taking part in the study is your and her choice. If you or she decide not to be in the study, there is no penalty. Your decision will not affect any government benefits or services she might receive. Your decision will not affect her ability to participate in the home visiting program. Only half of families will be able to receive home visiting services. If she is not selected for the home visiting program, she can use other services in your community.

Your daughter may stop being in the study at any time. She may refuse to answer any questions we ask. There will be no penalties and she will not lose any benefits to which she would be otherwise entitled.

Q: WILL THE INFORMATION BE KEPT CONFIDENTIAL?

The research team follows strict rules to protect the privacy of the information participants share with us. All study staff are trained to protect privacy and sign a privacy pledge. To protect participants’ privacy, the study has a Confidentiality Certificate from the U.S. government. This certificate states that we do not have to identify a participant, even under a court order or subpoena. In addition, the government may see your daughter’s information if it audits the study, but it would keep that information confidential. However, if keeping a participant’s answers confidential would put her or someone else in serious danger, then we will have to tell the appropriate agencies to protect the participant or the other person.

All information about a participant will be marked with a code number, not with a name. No reports will describe an individual in a way that would allow her to be identified. We have to deliver the study data to the federal government at the end of the study, but the data file will not contain information that could be used to identify any participant.

If you have questions at any time during the study, you may call MDRC toll-free at 1-877-311-6372.

Agreement for Home Visitor Supervisor to Take Part in the Maternal and Early Childhood Home Visiting Program Evaluation

We would like you to take part in an important research project to learn more about the effects of home visiting services. The project is being funded by the US Department of Health and Human Services. MDRC is conducting the study with James Bell Associates, Johns Hopkins University, and Mathematica Policy Research.. The study will give States and the federal government information to help them improve their services for parents with young children.

WHAT DOES IT MEAN TO BE IN THE STUDY?

About 100 home visiting supervisors will be in the study around the country. Home visiting staff members in 12 states are being asked to provide information to help improve home visiting programs.

If you agree to take part in the study, we will ask you to do the following:

Complete a web-based survey today.

This survey will take about 75 minutes to complete.

We will want to learn about you and your home visiting supervision experience and training. We will ask you to answer questions online about employment and supervision, roles and responsibilities, program outcomes, and professional consultation. We will also ask you some demographic questions and questions about your psychological well-being.

You will receive $30 for completing the survey.

Complete a web-based survey in the future.

In one year, you will be asked to complete a similar online survey. The survey will take about 75 minutes to complete.

You will receive $30 for completing any future survey.

RISKS AND BENEFITS

Participating in the study will help local, state, and federal agencies improve their home visiting services.

You will receive $30 each time you complete a web-based survey.

Some of the questions we ask involve sensitive topics. They may be stressful to answer. You may refuse to answer any questions, both today and in the future. There is a small risk that the information you sharing will be disclosed outside the study team. However, the study team follows strict rules to protect your privacy and we will keep your information confidential. No reports will include your name or other personally identifiable information. The information you give us will not be provided to your home visiting program in a way that could identify you.

BEING PART OF THE STUDY IS YOUR CHOICE

Taking part in the study is your choice. If you decide not to be in the study, there is no penalty. Your decision will not affect your employment with the home visiting program.

You may stop being in the study at any time. You may refuse to answer any questions we ask, both today and in the future.

INFORMATION WILL BE PRIVATE

The research team follows strict rules to keep your information private. All study staff are trained to protect privacy and sign a confidentiality pledge. All of your answers in the survey will remain private. If keeping your answers private would put you or someone else in serious danger, then we will have to tell the appropriate agencies to protect you or the other person.

If you have questions at any time during the study, please call MDRC toll-free at 1-877-311-6372.

Subject’s Statement:

“The research procedures, risks and benefits have been explained to me. I recognize that I am free to ask any questions. I understand that taking part in this study is my choice, and that being in it or not being in it will not affect my employment with the home visiting program. I understand that I am free to stop taking part in the study at any time. I understand that I can refuse to answer any question in the survey. I understand that any information that could be used to identify me will be kept private”.

 Checking this box will serve as your consent to take part in this research study.

Agreement for Home Visitor to Take Part in the Maternal and Early Childhood Home Visiting Program Evaluation

We would like you to take part in an important research project to learn more about the effects of home visiting services. The project is being funded by the US Department of Health and Human Services. MDRC is conducting the study with James Bell Associates, Johns Hopkins University, and Mathematica Policy Research. The study will give States and the federal government information to help them improve their services for parents with young children.

WHAT DOES IT MEAN TO BE IN THE STUDY?

About 510 home visitors will be in the study from 12 states around the country.

If you agree to take part in the study, we will ask you to do the following:

Complete a web-based survey today.

The survey should take about 75 minutes to complete.

We will want to ask about you and your home visiting experience and training. We will ask you to answer questions about employment and supervision, roles and responsibilities, program outcomes, program referrals, and knowledge of child development. We will also ask you some demographic questions and questions about your psychological well-being.

You will receive $30 for completing the survey today.

Complete a web-based survey in the future.

In one year, you will be asked to complete a similar online survey. The survey would take about 75 minutes to complete.

You will receive $30 for completing the survey.

Agree to be videotaped during some selected home visits with families in your caseload in the future.

We may ask to video record home visits between you and families in your caseload on some occasions. These videos will be used for research and research training purposes only.

RISKS AND BENEFITS

Participating in the study will help local, state, and federal agencies improve their home visiting services. You will receive $30 each time you complete a web-based survey.

BEING PART OF THE STUDY IS YOUR CHOICE

Taking part in the study is your choice. If you decide not to be in the study, there is no penalty. Your decision will not affect your employment with the home visiting program.

You may stop being in the study at any time. You may refuse to answer any questions we ask, both today and in the future. You may refuse to be recorded during home visits.

INFORMATION WILL BE PRIVATE

If you have questions at any time during the study, please call MDRC toll-free at 1-877-311-6372.

Subject’s Statement:

 Checking this box will serve as your consent to take part in this research study.

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