Appendix E - Child Informed Assent Interviewer Script

OMB Control # 0970 – XXXX

Expiration Date: XX/XX/XXXX

APPENDIX E

Childhood and Family Experiences Study

Informed Assent Form for Children

(Ages 7-11)

Interviewer Script

Hello, my name is ________ and I work at an organization named MDRC. I’m here today to talk with you while my colleague, ________, talks with your ________ [DETERMINE CHILD’S TERM FOR PCG/LEGAL GUARDIAN AND RELATIONSHIP AND USE THAT TERM HERE AND THROUGHOUT THE INTERVIEW]. Your ________ has said that it is O.K. for me to talk with you today as long as it is O.K. with you. We are trying to understand families’ experiences with money.

If you are O.K. talking with me today, I have some questions that will take about 30 minutes. There are no right or wrong answers to my questions; I just want to know what you think. I’ll start by asking a few questions about yourself, like what grade you’re in and what some of your favorite things are. Some questions are about what your life is like. For example, I have some questions about how much money your family has and if your ________ talks with you about money. Other questions ask about your ideas about the amount of money that other people have, such as why some people have a lot of money while others have very little money. Answering my questions is voluntary; it’s up to you. If you don’t feel like answering a question, just tell me and we will skip it and go on to the next question. If you decide you don’t want to do any more, please tell me and we can stop at any time. It is O.K. to tell me that you want to skip a question or stop. You can also let me know if you don’t understand a question so that I can repeat it or ask it a different way.

Your name will not be on any of the answer sheets, so no one will know how you answered these questions. Instead, my answer sheets will have a number on them, like this. [SHOW CHILD ID NUMBER ON THE ANSWER BOOKLET] Only the people I work with will be able to see the answer sheets I use today. We also have a special thing called a Certificate of Confidentiality from the U.S. government. This means we will not tell anyone what you tell us even if a judge or a court asks for it. The only time we will say anything is if the law says we have to say something. For example, if we are worried that you or someone else is in danger. If you tell us that you or someone else is getting hurt or may get hurt, we will tell people who are responsible for protecting children.

When you are done answering my questions today, you will get to pick a prize from the treasure chest I brought with me. Even if you choose not to answer some or any of my questions, you will still get to pick a prize. [BRING FORWARD AND OPEN THE TREASURE CHEST TO SHOW THE CHILD. THE CHEST SHOULD BE PLACED BEHIND THE INTERVIEWER DURING THE INTERVIEW SO AS NOT TO DISTRACT THE CHILD]. You can pick from a prize from the books, crayons, pencils, and notebooks you see here as a thank you for answering my questions today.

Even though your ________ has said it is O.K.to talk with you today, you can still decide not to do this. No one will be upset if you don’t want to answer my questions or if you change your mind and want to stop. Also, if you answer the questions but then change your mind later, your ________ can let me know and we will erase the interview and not use it in our study.

Do you have any questions before we start? [WRITE DOWN AND ANSWER CHILD’S QUESTIONS ]

If you have any questions that you think of later, I’ve given your ________ a number they can call to get your questions answered.

Are you willing to participate in an interview today? [CIRCLE CHILD’S RESPONSE]

YES

NO

[IF CHILD INDICATES NO, ASK WHY AND TRY TO ADDRESS CHILD’S CONCERNS. IF HE/SHE STILL DOESN’T SAY IT IS O.K., THANK CHILD, OFFER THEM A PRIZE FROM THE TREASURE CHEST, AND CONCLUDE. WRITE BRIEF EXPLANATION IN NOTES]

______________________________ _______

Interviewer’s Signature Date

CHILD’S PART

[HAND CHILD ASSENT FORM] I am going to read this next part with you. Your part of the form says: When I sign my name here I am saying that the information on this page has been read to or by me, and I agree to be interviewed for this study. I am also saying that I understand what I am being asked to do and that I may stop the interview at any time. [HAVE CHILD SIGN AND DATE ASSENT FORM] Please also fill in your birthdate as best you can.

CHILD NAME: ______________________________ DATE _______ BIRTHDATE _________

______________________________ _______

Child’s Signature Date

AUDIO RECORDING AUTHORIZATION

There is one more thing. I would like to turn on this recorder while we talk, so that I don’t have to try to write down everything you say. Is that okay with you?

YES [HAVE CHILD SIGN AND DATE AUDIO RECORDING PORTION OF ASSENT FORM]

NO [IF CHILD INDICATES NO, ASK WHY AND TRY TO ADDRESS CHILD’S CONCERNS. IF HE/SHE STILL SEEMS HESITANT TO HAVE YOU RECORD THE INTERVIEW SAY, “That’s okay – I will ask my questions and just take notes on what you say. We don’t have to use the recorder today.”]

______________________________ _______

Child’s Signature Date

Thank you. Here is a copy of this form for you to keep. You do not have to sign it if you don’t want to. [REMOVE AND GIVE CHILD BLANK COPY OF ASSENT FORM] O.K., now we are ready to get started.

____________________________________________________________________________________

This collection of information is voluntary and will be used to understanding the families’ experiences with money. Public reporting burden for this collection of information is estimated to average 30 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-XXXX, 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 Sam Wulfsohn at MDRC via e-mail at [email protected].