AIAN FACES 2019 special parent consent form for fall 2021 and spring 2022 data collection

Attachment 35

AIAN FACES 2019 Fall 2021 Special Parent Consent Form
for Fall 2021 and Spring 2022 Data Collection

This page has been left blank for double-sided copying.

AIAN FACES 2019 FALL 2021 SPECIAL PARENTCONSENT FORM FOR FALL 2021 AND SPRING 2022 DATA COLLECTION

We invite you and your child to take part in the American Indian and Alaska Native Head Start Family and Child Experiences Survey, known as AIAN FACES 2019 fall 2021 and spring 2022 data collection. AIAN FACES is an extension of the second round of the AIAN FACES study, which in 2015 became the first national study to collect information about the characteristics and experiences of children and families served by Head Start programs in American Indian and Alaska Native communities. The study will help us learn more about children and families in AIAN Head Start programs and the services Head Start provides. This study will help the Office of Head Start (OHS) better understand the families Head Start is serving and help them make decisions so that the program can better serve their needs. It is very important because it will help OHS understand the unique needs of Head Start families during the COVID-19 pandemic. We are inviting you and your child to participate because your child attends a Head Start program included in the AIAN FACES Study. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is paying for AIAN FACES. Mathematica, an independent firm, is conducting the study.

If you agree to take part…

We will ask you to fill a survey this fall and next spring via the web or over the phone. We will ask you about your child, your family’s activities and routines (such as eating meals together), your feelings, and your well-being during the COVID-19 pandemic. The surveys will take about 35 minutes each.

We will ask your child’s Head Start teacher some questions about your child. This will help us learn more about the progress your child is making in Head Start. Your child’s teacher will fill out a brief survey with questions about your child’s behavior, skills, and any special concerns or disabilities..

We will offer a gift card for your help. After you finish each survey, as a thank you, we will send you a $30 gift card.

You can choose whether you and your child will be part of the study. Taking part is completely voluntary. Your choice to take part or not will not affect the Head Start services you and your child receive. If you choose to take part in the study but then decide you want to leave the study at any point, that is okay.

We will protect your privacy. No one from Head Start will see or hear your answers to the questions in the parent survey. We may quote responses you provide to open-ended questions in order to illustrate a point, but any specific names or places (or any other information that could identify an individual, program, or community) you mention will be omitted from study reports. We will only report study results for parents, children, and programs as a group. All information collected as part of AIAN FACES will be kept private unless we learn that a child has been hurt or is in danger or you tell us that you plan to seriously hurt yourself or someone else – then by law, we must make a report to the appropriate legal authorities. In the future, survey responses from the study (with nothing identifying individuals, programs, or communities) may be securely shared with qualified individuals for additional learning purposes to better understand the strengths and needs of children and families in AIAN Head Start and the programs that serve them.

We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us protect your privacy. This means no one can force the study team to give out information that identifies you, even in court. However, we may need to share your information if it shows a serious threat to you or to others, including reporting to authorities when required by law. The U.S. Department of Health and Human Services (DHHS) may ask for data for an audit or evaluation. If they do, we will need to provide it. However, only DHHS staff involved in the review will see it.

If you have questions about AIAN FACES, please call Sara Skidmore, the deputy survey director, toll free at XXX-XXX-XXXX. You can find out more about AIAN FACES on the study website at http://www.acf.hhs.gov/programs/opre/research/project/american-indian-and-alaska-native-head-start-family-and-child-experiences-survey-faces.

We hope you will take part in this study. Please sign the attached consent form and return it to your child’s teacher right away if you would like to take part. Thank you! You may also provide consent online and complete your survey by visiting the following website: [URL].

I have read this consent form and understand what I am being asked to do.

I agree to have AIAN FACES study staff collect some information from my child’s Head Start teacher about my child’s behavior, skills, and any special concerns or disabilities. I also agree to take part in the study by filling out a survey this fall and again in the spring. There are a few open-ended questions in this survey. The information I provide as part of those open-ended questions may be directly quoted in order to illustrate a point, but any specific names or places (or any other information that could identify an individual, program, or community) that I mention will be omitted from study reports. I will receive a $30 gift card after I fill out the survey in the fall, and again after I fill out the survey in the spring. I can withdraw this consent at any time without penalty.

1. Child’s name (print)

2. Parent/guardian signature 2a. Today’s date

3. Parent/guardian name (print)

4. Your relationship to child  Mother  Father  Grandmother  Other guardian

5. Home phone ( )___________________

6. Cellular/other phone ( )___________________

6a. Does your cellular phone plan have unlimited minutes?*

 Yes  No

6b. May we send you text messages?*

 Yes  No

7. Address :

Address 1 Address 2

City State Zip

8. Email address

9. Do you have access to the internet through a smart phone, laptop, computer or other device?

 Yes  No

10. Child’s sex assigned at birth, on the original birth certificate  Male  Female

11. Child’s birthday

Month Day Year

12. What language would you like to use to complete your survey?  English  Spanish  Other

* In case you would like to complete your parent survey using your cell phone. Also, we may text you to remind you about the parent survey.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to provide descriptive information about Head Start programs and the families they serve. 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 #: 0970-0151, 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 Lizabeth Malone, Mathematica, 1100 1st Street, NE, 12th Floor, Washington, DC 20002.

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