Parent consent form

P.O. Box 2393 Princeton, NJ 08543-2393 Telephone (609) 799-3535 Fax (609) 799-0005 www.mathematica-mpr.com

BABY FACES SPRING 2018 CONSENT FORM

We invite you and your child to take part in the Early Head Start Family and Child Experiences Survey (Baby FACES 2018). We are inviting you because your child is in an Early Head Start program that is participating in this study.

Baby FACES 2018 seeks to learn more about the families in Early Head Start and about the kinds of services Early Head Start provides to families with infants and toddlers. This study will help Early Head Start serve all children and their families better. The Administration for Children and Families, part of the U.S. Department of Health and Human Services (DHHS), is funding Baby FACES. Mathematica Policy Research, an independent firm, is conducting the study.

If you agree to participate in this study…

We will interview you by phone. We will ask you questions about your family’s activities and routines, about your feelings, and about your health. We will also ask you to fill out a short questionnaire about the kinds of things your child can do. The telephone interview will take about half an hour, and the written questionnaire will take closer to 15 minutes. Both will be in either English or Spanish. As a thank you for your help, we will give you $25 after you complete the interview and fill out the questionnaire.

We will ask your child’s Early Head Start teacher or home visitor some questions, and (if your child is in a classroom that is part of the study) we will conduct an observation of that classroom. You can choose whether you and your child will be part of the study. Your participation is completely voluntary. All information collected during the course of Baby FACES will be kept private to the extent permitted by law. Your choice will not affect the Early Head Start services you and your child receive. If at any point you decide to leave the study, that is okay. No one from Early Head Start will see or hear your answers. We will only report the results for parents and children as a group.

To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this certificate, Mathematica can’t be forced to give out any information on you that is collected in the Baby FACES study. For example, we do not have to respond to a court order or subpoena. The certificate applies to any civil, criminal, or other proceedings. We will not respond to any demands for your information that would identify you or your child, with one exception. We will release information if doing so could prevent serious harm. We explain this below.

A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then we may not use the Certificate to withhold that information. We may need to take action to prevent serious harm to you or others. Action can include reporting to authorities. For example, we will report child abuse or neglect.

If you have any questions about the Baby FACES study, please call Laura Kalb, the survey director, toll free at 866‑XXX‑XXXX. If you have any questions about your rights as a research volunteer, please call New England IRB toll free at 1‑800‑757‑4778.

We hope you will agree to help us with this with this important project. Please sign the enclosed consent form and return it to your child’s home visitor or teacher right away. Thank you!

CONSENT FORM

I have read this consent form and understand what I am being asked to do. I understand that my child and I will take part in this study. I also agree to have Baby FACES researchers collect some information from my child’s Early Head Start teacher or home visitor. I also agree to participate in the study by completing a survey and a parent-child report. I understand that I may withdraw this consent at any time without penalty.

1. Parent/Guardian Signature: Date:

2. Parent/Guardian Name: (PRINT)

3. Relationship to Child:

4. Home Phone: Cell Phone:

Email: ______________________________ Permission to text at above number: Yes No

5. Address:

Street Address Apt. # City, State Zip Code

6. Child’s Name: (if applicable) (PRINT)

7. Child’s Gender: (if applicable)  Male  Female

8. Child’s Age: (if applicable)

9. Child’s Birthday/Expected Date of Birth:

Month Day Year

10. What language would you like us to interview you in?

 English  Spanish

This collection of information is voluntary and will be used to [insert brief statement]. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: 0970-0354, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [Contact Name]; [Contact Address].