Appendix G - Consent and Assent Forms

The Administration for Children and Families (ACF), an agency within the U.S. Department of Health and Human Services, provides funding for activities that support the well-being of children and families. ACF hired RTI International (RTI), a research company in North Carolina, to conduct a national survey of children and families in the child welfare system. RTI works with researchers from the University of North Carolina at Chapel Hill and Washington University in St. Louis to carry out the study

SELECTION OF PARTICIPANTS

RTI selected 4,500 children to take part in this study. All of the selected children had contact with the child welfare system during a 12-month period. As a part of the study, we conduct interviews with the child, the child’s caregiver, and with the caseworker. You have been identified as the primary caseworker of one or more participating children. We will follow up with sampled children and families in 18 months to conduct a second interview.

PURPOSE OF NSCAW CASEWORKER INTERVIEWS

The case worker interview collects information about the child’s history with the child welfare system and services recommended or provided by the agency. Your answers combined with the answers of others in the study will help us describe the needs of children and their use of available child welfare services. Research reports will summarize the collected information and help policy makers improve the child welfare system. We will not share your answers with the child or the child’s caregiver. They will not know how you responded to the questions.

TYPES OF QUESTIONS FOR CASEWORKERS

The caseworker interview takes about 45 minutes. The interviewer will ask you questions about the events surrounding the investigation/assessment, about characteristics of the family, and any factors that contributed to your report.

YOUR RIGHTS

You can decide to take part in this study or not. You can refuse to answer any and all questions. Your decision to take part will not affect you, your job, or any services the child may receive. You have the right to stop the interview at any time.

RISKS

Taking part in this study presents no physical risks to you. Some questions might make you feel uneasy or feel various emotions, such as sadness.

BENEFITS

Taking part in this study presents no direct benefits to you, the caregiver, or to the child. Your input will help us learn about the needs of children and the services available to them.

PRIVACY

We keep your responses private to the extent permitted by law. We keep your answers on a secure computer labeled with an ID number. Your name and that of the child will not be reported with any information you provide. We will combine your answers with thousands of others and report the information in summary form. All staff involved in this research have signed a Privacy Pledge. RTI obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

QUESTIONS

If you have questions, please call Jennifer Keeney at RTI, 1-800-334-8571 extension 23525 (toll-free number). If you have questions about your rights as a study participant, please call RTI's Office of Human Research Protection at 1-866-214-2043 (a toll-free number).

You will receive a copy of this consent form to keep.

The above information has been explained to me. My signature below indicates I give consent for my interview.

We use a laptop quality control (QC) system for this study. The system runs on the computer and may record what you and I say to each other. You and I will not know when the computer records our conversation. RTI project staff review the recordings to monitor my work. We use the recordings for those purposes only and we keep them private. We destroy the files after we conduct this review. Those project staff who listen to the recording will know who I am, but will not know who you are. Do we have your permission to run this system during your interview?

Check one box.

	Yes, I consent to having parts of this interview recorded by the computer for quality reviews.

	No, I do not want any part of this interview recorded.


Printed Name of Caseworker	Fill in CW Respondent 8-digit ID #	Printed Name of Youth

Signature of Caseworker	Signature of Interviewer	Date

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 #: 0970-0202, 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].

The Federal Government has issued a Certificate of Confidentiality (authorized by the Public Health Service Act Section 301(d), 42 U.S.C Section 241 (d), 1988) to the researchers who are conducting this study which authorizes us to protect the privacy of individuals who participate.

Caregiver Informed Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The Administration for Children and Families (ACF) provides funding for activities that support the well-being of children and families. ACF hired RTI International (RTI), a research company in North Carolina, to conduct a national survey of children and families in the child welfare system. RTI works with researchers at the University of North Carolina at Chapel Hill and Washington University in St. Louis to carry out the study.

SELECTION OF CHILDREN AND OTHER PARTICIPANTS

RTI selected 4,500 children to take part in this study. All of the children had contact with the child welfare system during a 12-month period. The study includes observations or interviews with selected children. The study also includes interviews with the child’s caregiver and case worker. We plan to interview children and their caregivers two times. We will schedule the second interview 18 months after the first interview. We must have permission from a parent or legal guardian to include the child in the study. This form explains the caregiver interview. A separate form explains the child’s part in the study. This forms explains the caregiver’s participation in the study and that interview.

PURPOSE OF THIS NSCAW CAREGIVER INTERVIEW

We want to interview you about your child and your experiences with the child welfare system. Your answers combined with answers of other caregivers in the study will help us describe the needs of children and their use of available child welfare services. What we learn from this information will help policy makers make improvements to the child welfare system.

TYPES OF QUESTIONS FOR CAREGIVERS AND OTHER INFORMATION GATHERED

The caregiver interview takes about 100 minutes. The length of your interview depends on the age of your child and other factors. The interview includes questions about your child’s learning, health, behavior, and relationships with friends. We will ask about services your family may receive and your level of satisfaction with those services. We also want to learn about your attitudes about raising children, your life experiences, and your involvement with school and community activities. The interviewer will ask about things that may happen in your family like violence in the home, drug abuse, and other risky behaviors such as drinking and involvement with the police. We will also take notes on what we see in your home such as toys you have. In addition, we will observe your interactions with your child and ask you to tell us about your relationship with your child.

YOUR RIGHTS

You can decide to take part in this study or not. You can refuse to answer any and all questions. Taking part in this study does not affect any benefits you or your child may receive.

RISKS

Taking part in this study presents no physical risks to you and your child. Some questions might make you feel uneasy or feel various emotions, such as sadness. If we learn a child’s life or health may be in danger during the interview, we will tell the appropriate authorities. The Privacy section provides more information below.

BENEFITS

Taking part presents no direct benefits to you or your child for answering our questions. What we learn from you may help to improve child welfare services and programs. By taking part, you will help us understand the needs of children and the services available to them.

FUTURE CONTACTS

We may contact you in eighteen months for another round of interviews. This will help us understand changes over time. You can decide whether to talk with us at that time.

PRIVACY

We keep your answers private to the extent allowed by law. We keep your answers on a secure computer labeled with an ID number. We do not identify you or your child by name. We combine your answers with the answers from thousands of others and report in summary form. To protect the privacy of both you and your child, neither of you will know the other’s interview answers. All staff involved in this research have signed a Privacy Pledge. In addition, RTI obtained a federal Certificate of Confidentiality for this study. This certificate prevents the release of information that would identify you with anyone, even from a court order.

Three important exceptions to note.

(1) We will tell the appropriate authorities if the interviewer or project staff think your child’s life or health may be in danger.

(2) Also, if we think your life or health may be in serious danger, we will contact someone qualified to assist you.

(3) At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give contacting information for you and your child to the other group.

QUESTIONS

If you have questions, please call Jennifer Keeney at the RTI, 1-800-334-8571 extension 23525 (toll-free number). If you have questions about your rights as a study participant, please call RTI 's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will receive a copy of this consent form to keep.

You will receive [INCENTIVE AMOUNT] in cash as a thank you for your input. If you take part in future interviews, you will receive a similar amount for those interviews.

The above information has been explained to me. My signature below indicates I give consent for my interview.

I give consent to have contact information for me given to another research company if they start doing this study.

Yes

Check one box.

We use a laptop quality control (QC) system for this study. The system runs on the computer. This system will make audio recordings that we will use for two purposes.

The computer will record parts of what you and I say to each other during the interview. Project staff at RTI will review the recordings to monitor my work. Project staff who listen to the recordings will know who I am, but they will not know who you are.
We would also like to record the last part of the interview. In this part, we will ask parents and caregivers to talk in their own words, about their thoughts and feelings about their child. We will use this recording to better understand the child’s family environment. We will record this part of the interview to fully and accurately capture what you say. Project staff will listen to the recording and change your answers into codes that express your main ideas. We will only use the codes in our study.

We will not use these recordings for any other purposes and we will keep them private. We will destroy the files at the end of the study after the data is delivered to the sponsor.

Do we have your permission to run this system during the interview?

Check one box.

	Yes, I agree to have parts of this interview recorded by the computer.

	No, I do not want any part of this interview recorded.


Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Caregiver Permission for Child Participation

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF CHILDREN AND OTHER PARTICIPANTS

RTI selected 4,500 children to take part in the study. All of the children had contact with the child welfare system over a 12-month period. The study includes observations or interviews with selected children. The study also includes interviews with the child’s caregiver and case worker. We will follow up with sampled children and their caregivers 18 months after the first interview. We must have permission from a parent or legal guardian to include the child in the study.

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview your child about their experiences with the child welfare system, you, and your family. The child’s answers combined with the answers of others in the study will help us describe the needs of children and their use of available child welfare services.

TYPES OF QUESTIONS FOR CHILD

The interview with your child will last approximately 60 to 90 minutes. The length depends on the child's age and other factors. We will assess younger children on their language skills and how well they understand and perform certain tasks. We will also weigh and measure younger children. The interviewer will talk with older children about their development, family experiences, school, friends, and their exposure to violence.

YOUR CHILD’S RIGHTS

You and your child can decide to take part in this study or not. Your child can refuse to answer any and all questions. If your child chooses not to join, this would not affect any benefits or services your family may be receiving. Your child has the right to stop the interview at any time.

RISKS

Taking part in this study presents no physical risks to your child. Some questions might make your child feel uneasy or feel various emotions, such as sadness. If we learn a child’s life or health may be in danger during the interview, we will share this information with the appropriate authorities. The Privacy section provides more detail below.

BENEFITS

What we learn from your child may help to improve child welfare services and programs. By taking part, your child will help us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

We may contact you and your child in eighteen months for another round of interviews. This will help us understand changes over time. You and your child can decide at that time if you want to join.

PRIVACY

We keep your child’s responses private to the extent allowed by the law. We keep your child’s interviews answers on a secure computer labeled with an ID number. We keep you and your child’s name private. Information your child provides will be combined with answers of thousands of others and reported in summary form. To protect the privacy of both you and your child, neither of you will know the other’s interview answers. All staff involved in this research have signed a Privacy Pledge. In addition, RTI obtained a federal Certificate of Confidentiality for this study. This certificate prevents the release of information that would identify your child with anyone, even from a court order.

Three important exceptions to note.

(1) We will inform the appropriate authorities if the interviewer or project staff think your child’s life or health may be in danger. (2) Also, if we think your life or health may be in serious danger, we will contact individuals qualified to assist you.

QUESTIONS

If you have questions, please call Jennifer Keeney at the RTI, 1-800-334-8571 extension 23525 (toll-free number). If you have any questions about your rights as a study participant, you may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will receive a copy of this consent form to keep.

We will give your child a gift certificate for participating. Children ages 11 or older will receive $20; children 10 and under will receive $10. If your child participates in future interviews, a similar amount will be offered for participating in those interviews.

The above information has been explained to me. My signature indicates I give my consent for my child to be approached for an interview.

I give consent to have contact information for me and my child given to another research company if they start doing this study.

Check one box.

Yes

We use a laptop quality control (QC) system for this study. The system runs on the computer. This system will make audio recordings of what the child and I say to each other during the interview. Project staff at RTI will review the recordings to monitor my work. Project staff who listen to the recordings will know who I am, but they will not know who the child is.

We will not use these recordings for any other purposes and we will keep them private. We will destroy the files after we conduct this review.

Do we have your permission to run this system during the child’s interview?

Check one box.

	Yes, I agree to have parts of the child’s interview recorded by the computer.
	No, I do not want any part of the child’s interview recorded.

Printed Name of Parent/Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Parent/Caregiver	Signature of Interviewer	Date

Legal Guardian Permission for Child Participation

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF CHILDREN AND OTHER PARTICIPANTS

RTI interviewers will contact families of children selected from child welfare agencies throughout the United States to invite them to take part. The study includes interviews with sampled children, their caregivers and their caseworkers. A child under your guardianship was one of 4,500 children selected to take part in this study. We must have permission from a parent or legal guardian to include the child in the study. Once we obtain your permission, the child can make the decision to take part in the study.

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview the child, their current caregiver, and their caseworker. Their responses combined with the answers of others in the study will help us describe the needs of children and families and their use of available child welfare services. Research reports will summarize the information collected and assist policy makers in improving the child welfare system.

TYPES OF QUESTIONS FOR CHILD

The interview with the child will last about 60 to 90 minutes. The length depends on the child’s age and other factors. We will observe younger to assess their language skills and how well they perform certain tasks. We will also weigh and measure younger children. We will interview older child to find out about the kinds of things they can do, their experiences at home and at school, their feelings about family and friends, and their exposure to violence.

THE CHILD’S RIGHTS

The child’s participation in this study is completely voluntary. He or she can refuse to answer any and all questions. Taking part in the study will not affect any benefits the child may receive. The child has the right to stop the interview at any time.

RISKS

Taking part in this study presents no physical risks to the child. Some questions might make the child feel uneasy or feel various emotions, such as sadness. Some answers to questions will require that we share that information with the appropriate authorities. The Privacy section below provides more detail.

BENEFITS

Taking part in this study presents no direct benefits to the child. By taking part, the child will help us learn more about the needs of children and the services available to them.

FUTURE CONTACTS

We will contact the child in eighteen months for another round of interviews. This will help us understand changes over time.

PRIVACY

We will keep the child’s responses private to the extent permitted by law. We keep the child’s interview answers on a secure computer labeled with an ID number. We do not identify the child by name. We combine the child’s information with answers of many others and report in summary form. To protect the privacy of the child, neither the child nor the caregivers will know the other’s interview answers. All staff involved in this research have signed a Privacy Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

Two important exceptions to note.

(1) We will inform the appropriate authorities if the interviewer or project staff think the child’s life or health may be in danger. (2) At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give contacting information for the child to the other group.

QUESTIONS

If you have questions, please call Jennifer Keeney at the RTI, 1-800-334-8571 extension 23525 (toll-free number). If you have questions about the child’s rights as a study participant, please may call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will receive a copy of this consent form to keep.

The current caregiver will receive $50 in cash in appreciation of their input. We will also give each child a gift certificate for taking part in the study. Children ages 11 and older will receive $20; children 10 and under receive $10.

My signature indicates the interviewer explained the above information to me. As the legal guardian, I give the interviewer permission to approach the child named below for an interview.

I give consent to have contact information for the child given to another research company if they start doing this study.

Yes

Check one box.

We use a laptop quality control system for this study. The system runs on the computer and may record what the child and I say to each other during parts of the interview. Neither the child nor I will know when the computer records what we say. The recording will be reviewed by project staff at RTI to monitor my work. We use the recordings for those purposes only and we keep them private. We destroy the files after we conduct this review. Those project staff who listen to the recording will know who I am, but will not know who the child is. Do we have your permission to run this system during the child’s interview?

Check one box.

	Yes, I consent to having parts of the child’s interview recorded by the computer for quality reviews.

	No, I do not want any part of the child’s interview recorded.


Printed Name of Legal Guardian	Fill in Child Respondent 8-digit ID #	Printed Name of Child

Signature of Legal Guardian	Signature of Interviewer	Date

Caregiver of Emancipated Youth Informed Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

The Administration for Children and Families (ACF) provides funding for activities that support the well-being of children and families. ACF has hired RTI International (RTI), a research company in North Carolina, to conduct a national survey of children and families in the child welfare system. RTI works with researchers at the University of North Carolina at Chapel Hill and Washington University in St. Louis to carry out the study.

SELECTION OF CHILDREN AND OTHER PARTICIPANTS

RTI selected 4,500 children to take part in this study. Selected children had contact with the child welfare system during a 12-month period. The study also includes interviews with the child’s caregiver and case worker. We selected a child currently or very recently in your care to take part in the study. That child gave us their permission to approach you for an interview.

PURPOSE OF THIS NSCAW INTERVIEW

We want to interview you about the child, your experiences with the child welfare system and your family. Your answers combined with the answers of other caregivers in the study will help us describe the needs of children and their use of available child welfare services. What we learn from this information will help policy makers make improvements to the child welfare system.

TYPES OF QUESTIONS FOR PARENT

Your interview may last up to 100 minutes. The interview includes questions about the child’s learning, health, behavior, and relationships with friends. For older children, we ask about their involvement in potentially risky behaviors. We also ask about services your family may receive and your satisfaction with those services. We want to learn about your attitudes about raising children, your life experiences, and your involvement with school and community activities. The interviewer will also ask you about the community in which you live, and about things that may happen in your life like violence in the home, involvement with police and risky behaviors such as sexual activity and drug use.

YOUR RIGHTS

You can decide to take part in this study or not. You can refuse to answer any and all questions. Taking part in the study does not affect any benefits you or the youth may receive. You have the right to stop the interview at any time.

RISKS

Taking part in the study presents no physical risks to you. Some questions might make you feel uneasy or feel emotions like sadness. If we learn a child’s life or health may be in danger during your interview, we will share this information with the appropriate authorities. The Privacy section provides more detail below.

BENEFITS

What we learn from you can help to improve child welfare services and programs. By taking part, you will help us understand the needs of children and services available to them.

FUTURE CONTACTS

To help us understand changes over time, we will contact your child in eighteen months for another round of interviews.

PRIVACY

We keep your responses private to the extent allowed by the law. We keep your interview answers on a secure computer labeled with an ID number. We never identify you by name. We combine your answers with the answers of many others and report in summary form. To protect the privacy of both you and the youth selected for this study, neither of you will know the other’s interview answers. All staff involved in this research have signed a Privacy Pledge. In addition, RTI obtained a federal Certificate of Confidentiality for this study. This certificate prevents the release of information that would identify you with anyone, even from a court order.

Three important exceptions to note.

(1) We will inform the appropriate authorities if the interviewer or project staff think your child’s life or health may be in danger.

(2) Also, if we think your life or health may be in serious danger, we will contact individuals qualified to assist you. (3) At some point in the future this research may be done by another research group. If that happens, with your consent, we would give contacting information for you and the youth to the other group.

QUESTIONS

If you have questions, please call Jennifer Keeney at the RTI, 1-800-334-8571 extension 23525 (toll-free number). If you have any questions about your rights as a study participant, please call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will receive a copy of this consent form to keep.

You will receive $50 in cash in appreciation of your input. If you participate in future rounds, we will provide a similar amount in appreciation of your participation in those interviews.

The above information has been explained to me. My signature below indicates I give consent for my interview.

I give consent to have contact information for me given to another research company if they start doing this study.

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Shape2

Check one box.

We use a laptop quality control (QC) system on this study. The system runs on the computer and may record what you and I say to each other during parts of the interview. You and I will not know when the computer records what we say. Project staff at RTI will review the recordings to monitor my work. We use the recordings for those purposes only and we keep them private. We destroy the files after we conduct this review. Those project staff who listen to the recording will know who I am, but will not know who you are. Do we have your permission to run this system during the interview?

Check one box.

	Yes, I agree to have parts of this interview recorded by the computer for quality reviews.

	No, I do not want any part of this interview recorded.


Printed Name of Caregiver	Fill in CCG Respondent 8-digit ID #	Printed Name of Youth

Signature of Caregiver	Signature of Interviewer	Date

Emancipated Youth Consent Form / Permission for Caregiver Interview

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF YOUTH AND OTHER PARTICIPANTS

RTI interviewers will contact families of youth, like you, selected from child welfare agencies throughout the United States. We selected over 4,500 youth to participate in this study. The study also includes interviews with caregivers and case workers.

PURPOSE OF THIS NSCAW INTERVIEW

Your interview may take about 100 minutes to complete. We want to interview you about the kinds of things you can do, how you behave at home and at school, and your feelings about family and friends. We want to learn about people who may help you. We also want to ask about things your parents don’t know about or don’t like for you to do. This includes skipping school, smoking, drinking, vandalism, using drugs, sexual activities, and other risky or illegal behaviors. Your answers, combined with the answers of other youth in the study, will help us describe the needs of children and their use of available child welfare services. What we learn from this information will help policy makers make improvements to the child welfare system. If you live with or have lived with a parent, grandparent, or other adult who took care of you in the last three months, we will request your permission to speak with that person.

PURPOSE OF THE NSCAW CAREGIVER INTERVIEW

The interview with the person who took care of you may last up to 100 minutes. We will ask them questions about services your family receives, family relationships and support, life experiences, and involvement with school and community activities. We will also ask questions about your learning, behavior, health, and friendships.

YOUR RIGHTS

You can decide to take part in the study or not. You can refuse to answer any and all questions. Taking part does not affect any benefits you may receive. You have the right to take a break or stop the interview at any time.

RISKS

Taking part in this study presents no physical risks to you. Some questions might make you feel uneasy or feel various emotions, such as sadness.

BENEFITS

Taking part presents no direct benefits to you for answering our questions. What we learn from you may help to improve child welfare services and programs.

FUTURE CONTACTS

We will contact you in eighteen months for a second interview. This will help us understand changes over time. You can decide to join at that time.

PRIVACY

We keep your responses private to the extent allowed by the law. We keep your interview answers on a secure computer labeled with an ID number. We do not identify you by name. We combine the information you provide with the answers of many others and report in summary form. All staff involved in this research signed a Privacy Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

Three important exceptions note.

(1) We will inform the appropriate authorities if the interviewer or project staff think your life or health may be in danger.

(2) Also, if you have a child whose life or health may be in serious danger, we will contact someone qualified to assist them.

(3) At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give contacting information for you to the other group.

QUESTIONS

If you have any questions, please call Jennifer Keeney at RTI, 1-800-334-8571 extension 23525 (toll-free number). If you have any questions about your rights as a study participant, please call RTI’s Office of Human Research Protections, 1-866-214-2043 (toll-free number).

You will receive a copy of this consent form to keep.

You will receive $50 in cash in appreciation of you completing the interview. If you participate in future interviews, we will provide a similar amount in appreciation of your participation in those interviews.

My signature indicates the interviewer explained the above information to me and I give consent for my interview.

I give consent to have my contact information given to another research company if they start doing this study.

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Check one box.

I live with or have lived with a caregiver in the last three months. I give my permission for the interviewer to approach my current / most recent caregiver for an interview.

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Shape6

Check one box.

We use a laptop quality control (QC) system on this study. The system runs on the computer and will record what you and I say to each other during parts of the interview. Neither you nor I will know when the computer records what we say. My bosses will listen to the recordings to monitor my work. We keep the recordings for those purposes only and we keep them private. We destroy the files after this review. Project staff who listen to the recording will know who I am, but will not know who you are. Do we have your okay to run this system during the interview?

Check one box.

	Yes, I agree to have parts of this interview recorded by the computer for quality reviews.

	No, I do not want any part of this interview recorded.


Printed Name of Youth	Fill in Youth Respondent 8-digit ID #

Signature of Youth	Signature of Interviewer	Date

Assent Agreement for Youth Aged 7 to 10

National Survey of Child and Adolescent Well-Being (NSCAW)

Hello, my name is __________________. ______________ has given permission for you to talk with me.

Introduction

We want to tell you about a research study. A research study is a way to learn more about something. We would like to learn about children and families. You can take part or not. Either way is fine. If you join, you can ask questions at any time. Just tell me if you have any questions.

Purpose

The government wants to learn about the needs of children like yourself. They want to improve programs and services for children. We are talking to over 4,500 kids across the United States about this study. We are also talking to one of your parents or the person who takes care of you the most. The government hired a research company in North Carolina to conduct this study. I work for this research company.

Types of Questions

If you join the study, we will ask you questions about the kinds of things you can do and how you behave at home and at school. We will also ask about your feelings towards family and friends. Some other questions are about school and people who may help you. We also ask questions about things that may have happened in your home that scared or hurt you like violence in the home.

Time Involved

Our talk today will last about one hour.

Possible Risks

We ask questions that might make you feel uneasy or sad. You may find some of these questions bring back sad or frightening memories. If you want to stop, then all you have to do is tell me. If you do not want to answer a question, just tell me. If you want to take a break at any time, just let me know.

Possible Benefits

What we learn from this study might help children like you across the U.S.

Payment

When we finish, I will give you a $10 gift card for taking part.

Privacy

We do many things to make sure your answers stay private. I am going to enter your answers into a laptop computer. We have a paper from the government that promises that we do not have to give your information to anyone. We will not tell anyone your answers unless we are worried about you or someone else’s safety. For example, if you tell us you might hurt yourself or someone else we may tell someone. If you tell us someone hurts you, we may tell authorities to keep people safe.

Future Contacts

We will contact you in eighteen months. This is to see if you want to talk to us again. You can decide at that time if you want to talk to us again.

I will give you a copy of this form to keep.

May I talk to you and ask you questions?

	YOUTH AGREES

	YOUTH DOES NOT AGREE

	YOUTH DID NOT APPEAR TO UNDERSTAND EXPLANATION

By signing this form, this shows we have discussed the research study. Your signature shows you agree to take part.

Signature of Youth

Signature of Interviewer

Date

Audio Recording

We use a quality control (QC) system on the computer. The system runs on the computer and may record what you and I say to each other. You and I will not know when the computer records what we say. My bosses will listen to the recordings to make sure I’m doing a good job. We keep the recordings for those purposes only and we keep them private. We will destroy the files after this review. Project staff who listen to the recording will know who I am, but will not know who you are. Do we have your okay to run this system while we talk?

Check one box.

Yes, I agree to have parts of our talk today recorded by the computer.

No, I do not want any parts of our talk today recorded.

Assent Agreement for Youth Aged 11 to 17

National Survey of Child and Adolescent Well-Being (NSCAW)

Hello, my name is __________________. ______________ has given permission for you to talk with me today.

Introduction

We would like to invite you to join a research study. A research study is a way to find out new information about something. You can take part or not. Either way is fine. Please ask any questions before you decide.

Purpose

The government wants to learn about the needs of children like yourself and to help improve programs and services for children. We are talking to over 4,500 kids across the United States about this study. We are also talking to one of your parents or the person who take cares of you the most. The government hired a research company in North Carolina to do this study of children and families. I work for this research company.

Types of Questions

If you agree to join, we will ask questions about the kinds of things you can do, how you behave at home and at school, how you feel about your family and friends, and about people who may help you. We also want to ask you about things you may do that your parents don’t know about or don’t like for you to do. This includes things like skipping school, smoking, drinking, vandalism, using drugs, sexual activities, and other risky or illegal behaviors. We also ask questions about things that may have happened in your life like violence in the home. You may find that some of these questions bring back sad or frightening memories.

Time Involved

Our talk today will last around one to one and a half hours.

Possible Risks or Discomforts

We ask questions that might make you feel uneasy or sad. You do not have to answer questions you do not want to answer. If you want to stop, then all you have to do is tell me. If you want to take a break at any time, just tell me.

Possible Benefits

What we learn from this study might help children like you across the U.S.

Payment

When we finish, I will give you a $20 gift card for taking part.

Privacy

Future Contacts

We will contact you in eighteen months. This is to see if you want to talk with us again. You can decide at that time if you talk to us again.

You will receive a copy of this form to keep.

May I talk to you and ask you the questions?

	YOUTH AGREES

	YOUTH DOES NOT AGREE

	YOUTH DID NOT APPEAR TO UNDERSTAND EXPLANATION

By signing this form, this shows we have discussed the research study. Your signature shows you agree to take part.

Signature of Youth

Signature of Interviewer

Date

Audio Recording

We use a quality control (QC) system on the computer. The system runs on the computer and may record what you and I say to each other. You and I will not know when the computer records what we say. My bosses will listen to the recordings to monitor my work. We keep the recordings for those purposes only and we keep them private. We destroy the files after this review. Project staff who listen to the recording will know who I am, but will not know who you are. Do we have your okay to run this system during the interview?

Check one box.

Yes, I agree to have parts of this interview recorded by the computer.

No, I do not want any parts of this interview recorded.

Young Adult Informed Consent

National Survey of Child and Adolescent Well-Being (NSCAW)

NSCAW

SELECTION OF YOUNG ADULTS

RTI selected 4,500 children to take part in this study. We interviewed selected children eighteen months ago as a part of our first round of interviews. We would like to interview you now to understand changes over time and to update our information.

PURPOSE OF THIS NSCAW INTERVIEW

Your interview may last 100 minutes. The interviewer will ask questions about your life experiences. The questions focus on your health, employment, relationships, social support system, behaviors, and use of services. The interviewer will also ask about the community in which you live, and about things that may happen in your life like violence in the home, drug abuse, and other risky behaviors such as drinking, sexual activity, and involvement with the police. Your answers combined with the answers of other young adults in the study will help us describe the transition to adulthood and outcomes of young people who have come into contact with the child welfare system. Research reports will summarize the information collected and assist policy makers in making improvements to the child welfare system.

YOUR RIGHTS

RISKS

Taking part in this study presents no physical risks to you. Some questions might make you feel uneasy or feel emotions like sadness.

BENEFITS

Taking part offers no direct benefits to you for answering our questions. What we learn from you may help to improve child welfare services and programs.

FUTURE CONTACTS

We or other researchers may contact you in the future to ask you to take part in another interview. You can decide to join at that time.

PRIVACY

We keep your responses private to the extent allowed by the law. We keep your interview answers on a secure computer labeled with an ID number. We do not identify you by name. We combine the information you provide with the answers of many others and report the results in a summary form. All staff involved in this research have signed a Privacy Pledge. In addition, RTI has obtained a federal Certificate of Confidentiality for this study to protect the identity of the research subjects.

Two important exceptions to note.

(1) We will inform the appropriate authorities if the interviewer or project staff think your life or health may be in danger.

(2) At some point in the future, a different group of researchers may take over this study. If that happens, with your consent, we would give contacting information for you to the other group.

QUESTIONS

If you have questions, please call Jennifer Keeney at RTI, 1-800-334-8571 Extension 23525 (toll-free number). If you have questions about your rights as a study participant, please call RTI's Office of Human Research Protections at 1-866-214-2043 (a toll-free number).

You will receive a copy of this consent form to keep.

You will receive $50 in cash in appreciation of you taking part in the interview. If you take part in future interviews, we will provide a similar amount in appreciation of your participation in those interviews.

The above information has been explained to me. My signature below indicates I give consent for my interview.

I give consent to have my contact information given to another research company if they start doing this study.

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Check one box.

We use a laptop quality control (QC) system for this study. The system runs on the computer and may record what you and I say to each other during parts of the interview. Neither you nor I will know when the computer records what we say. Project staff at RTI will review the recordings to monitor my work. We only use the recordings for those purposes and we keep them private. We will destroy the files after we conduct this review. Those project staff who listen to the recording will know who I am, but will not know who you are. Do we have your permission to run this system during the interview?

Check one box.

	Yes, I agree to have parts of this interview recorded by the computer for quality reviews.

	No, I do not want any part of this interview recorded.


Printed Name of Young Adult	Fill in YA Respondent 8-digit ID #

Signature of Young Adult	Signature of Interviewer	Date

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Keeney, Jennifer
File Modified	0000-00-00
File Created	2021-01-15