Parent Consent Form

OMB CONTROL NUMBER: 0704-XXXX
OMB EXPIRATION DATE: XX/XX/XXXX
CONSENT FOR RESEARCH
The Pennsylvania State University
Title of Project: Navy New Parent Support Program Evaluation
Principal Investigator: Dr. Ryan P. Chesnut
Address: 402 Marion Place, University Park, PA 16802
Telephone Number: (814) 865-9637
We are asking you to be in a research study. This form gives you information about the research.
Whether or not you take part is up to you. You can choose not to take part. You can agree to take part
and later change your mind. Your decision will not be held against you and there will be no penalty or
loss of benefits to which you are entitled.
Please ask questions about anything that is unclear to you and take your time to make your choice.
1. Why is this research study being done?
This research is being done to improve Navy NPSP home visitation programming effectiveness and
to ensure that Navy families can rely on high quality home visitation programs for new parents.
Approximately 300 participants will take part in this research study across 6 CONUS installations.
2. What will happen in this research study?
Whether or not you agree to participate in the evaluation, you will receive NPSP home visits and
programming. Home visits will involve using the Take Root Home Visitation curriculum or services as
usual depending upon your installation.
Following your agreement to participate, you will provide your email address. You will then be
identified in our system with a participant ID number so that your name is not linked to your
responses.
You will be asked to complete surveys following your agreement to participate (Time 1) as well as 34 months from now (Time 2), 6-7 months from now (Time 3), and at NPSP service or study completion,
whichever occurs first. You are free to skip any questions on the survey that you would prefer not to
answer. Following your participation, the survey data you complete will be linked to data collected by
your home visitor and Navy FAP via your participant ID number.
3. What are the risks and possible discomforts from being in this research study?
The likelihood and severity of harm or discomfort anticipated in this research is not greater than those
ordinarily encountered in daily life or during performance of routine psychological examinations. Some
of the questions may make you feel uncomfortable about your responses and/or question your own
attitudes/behaviors. You may decline answering questions and/or withdraw from participation without
penalty.

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There is a risk of loss of confidentiality if your information or your identity is obtained by someone other
than the investigators, but precautions will be taken to prevent this from happening. The confidentiality
of your electronic data created by you or by the researchers will be maintained to the degree permitted
by the technology used. Absolute confidentiality cannot be guaranteed.
4. What are the possible benefits from being in this research study?
4a. What are the possible benefits to you?
There is no guarantee that you will benefit from this research. The possible benefits you may
experience from this research study include helping you identify areas in which you would like your
home visitor to work with you and your family.
4b. What are the possible benefits to others?
By participating in the evaluation of the Navy NPSP home visitation programming, you have the
opportunity to help shape the future of the Navy NPSP home visitation program. Your participation will
help ensure future NPSP families receive high quality home visitation programs for new parents.
5. What other options are available instead of being in this research study?
Your participation in the evaluation is voluntary and there is no penalty for not participating. You
may decide not to participate in this research. Whether or not you agree to participate in the
evaluation, you will receive NPSP home visits and programming. Participation, or non-participation,
in the evaluation will not influence the services provided to your family.
6. How long will you take part in this research study?
If you agree to take part, it will take you about 30-60 minutes to complete the surveys at each time
point in this research study. You will be asked to complete surveys four times over the course of
approximately 12 months.
• Time 1 is anticipated to take <40 minutes.
• Time 2 is anticipated to take <20 minutes.
• Time 3 is anticipated to take <50 minutes.
• The NPSP service or study completion time point is anticipated to take <50 minutes each.
7. How will your privacy and confidentiality be protected if you decide to take part in this research
study?
7a. What happens to the information collected for the research?
Efforts will be made to limit the use and sharing of your personal research information to people who
have a need to review this information. The Navy (e.g., Command, Family Advocacy Program, and
NPSP) will not know if your family chooses to participate in the evaluation or your responses.
Reasonable efforts will be made to keep the personal information in your research record private.
However, absolute confidentiality cannot be guaranteed.
•

A list that matches your email address with your ID number will be kept in a password protected file
located in a password protected folder on a secure server requiring two-factor authentication.

•

Your research records will be labeled with your ID number and will be kept in a safe area in a
password protected data file in a password protected folder on a secure server requiring two-factor
authentication.

In the event of any publication or presentation resulting from the research, no personally
identifiable information will be shared.

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We will do our best to keep your participation in this research study confidential to the extent
permitted by law. However, it is possible that other people may find out about your participation in this
research study. For example, the following people/groups may check and copy records about this
research.
• The Office for Human Research Protections in the U. S. Department of Health and Human
Services
• The research study sponsor, the National Institute of Food and Agriculture
• The Institutional Review Board (a committee that reviews and approves research studies) and
Penn State’s Human Research Protection Program.
7b. What will happen to my research information and/or samples after the study is completed?
Your information or samples that are collected as part of this research will not be used or
distributed for future research studies, even if all of your identifiers are removed.
8. What are the costs of taking part in this research study?
There are no costs associated with taking part in this research study.
9. Will you be paid or receive credit to take part in this research study?
You will receive a $30 Amazon e-gift card for completing the Time 1 assessment, a $20 Amazon egift card for completing the Time 2 assessment, a $25 Amazon e-gift card for completing the Time 3
assessment, and a $25 Amazon e-gift card for completing the NPSP service or study completion
assessment. Thus, the total amount of Amazon e-gift card compensation for completing all four
assessments is $100. If you do not complete the study for any reason, you will be paid for the
assessments you have completed.
10. Who is paying for this research study?
The institution and investigators are receiving a grant from the National Institute of Food and
Agriculture to support this research.
11. What are your rights if you take part in this research study?
Taking part in this research study is voluntary.
§ You do not have to be in this research.
§ If you choose to be in this research, you have the right to stop at any time.
§ If you decide not to be in this research or if you decide to stop at a later date, there will be no
penalty or loss of benefits to which you are entitled.
12. If you have questions or concerns about this research study, whom should you call?
Please call the head of the research study (principal investigator), Ryan P. Chesnut at 814-865-9637 if
you:
§ Have questions, complaints or concerns about the research, including questions about
compensation.
§ Believe you may have been harmed by being in the research study.
You may also contact the Human Research Protection Program at (814) 865-1775, [email protected] if
you:
§ Have questions regarding your rights as a person in a research study.
§ Have concerns, complaints, or general questions about the research.
§ You may also call this number if you cannot reach the research team or wish to offer input or
to talk to someone else about any concerns related to the research.
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INFORMED CONSENT TO TAKE PART IN RESEARCH
Selecting “Yes” below implies your voluntary consent to participate in the research.
o Yes
o No
Selecting “Yes” below implies your voluntary consent to allow data about your child collected by your home
visitor to be included in the research.
o Yes
o No
On the following screen, you will be asked to provide your email address. Your email is how you will receive
links to access study surveys and Amazon e-gift cards for completing study surveys. A copy of this form will
be sent to the email address you provide for your records.

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