Attachment 22 - Video Consent Child

Agreement to participate for your child

Building Bridges and Bonds (B3) Study

Congratulations on your child being part of the Just Beginning program. The program is part of a project to learn what services benefit fathers and their families. When you sign this form, you agree your child can be video-recorded for research purposes. Your decision is voluntary. Your child can still be in the program if you choose to not sign the form.

Why is Just Beginning part of a study?

Because we want to learn what services benefit fathers and their families. The study is called Building Bridges and Bonds. Most of the study activities are about the fathers. But there is a small part for your child, if you approve.

What does it mean to participate?

The study team might like to record your child during the play time that will be scheduled with his or her father. You do not need to do anything extra.  We will record the videos and will only use them for research purposes. 

Is participation my choice?

Yes, recording your child during the program is your choice. You may change your mind at any time.

How will my child’s information be protected?

The study will follow strict rules to protect your child’s personal information. The team is trained to protect personal information. The team signs a pledge to keep the information private.

The study has a Certificate of Confidentiality from the U.S. government. This certificate says that we do not have to identify research subjects, even under a court order or subpoena. We will keep your child’s information private to the extent permitted by law. For example, if there is concern that your child or someone else may be harmed, we will have to tell the appropriate agencies to protect your child and that other person. The government may see your child’s information if it audits the study, but it would keep the information private.

No reports that we write about the study will identify your child.

What are the risks and benefits?

The recordings might help improve services for fathers and their families. There is a small risk of information being seen for non-research purposes in the unlikely event of a data breach, such as a breach in computer security. However, we follow strict rules to protect research data.

What if I have questions?

You can reach MDRC and Building Bridges and Bonds (B3) at [email protected] or 1-855-907-6703.

Participant’s statement:

“I agree to have my child’s image and voice recorded for the B3 project. Videos will show my child and his/her father playing together. I understand that only the image and voice of my child will be used for research purposes. Videos will not be sold. They will not be used for commercial purposes.

The video-recording procedures, risks, and benefits have been explained to me. I know I am free to ask any questions. I understand it is my choice. I understand my child’s information will be kept private, to the extent permitted by law, unless there is a concern that my child or someone else may be harmed.”

 By checking this box, I give permission to include the video-recording of my child in a presentation about the B3 study that would be available to the public, for example at a research conference or on a web site about the study.

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This evaluation is being conducted on behalf of the Administration for Children and Families (ACF). 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 for this information collection is 0970-0485 and the expiration date is 9/30/2019.

Your Name (Print) Your Signature Date

This evaluation is being conducted on behalf of the Administration for Children and Families (ACF). 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 for this information collection is 0970-0485 and the expiration date is 9/30/2019.