Final 1-18-23-Appendix F_Parent Permission Form

OMB Clearance Number: 2528-0259
Expires: xx/xx/xxxx

The Family Options Study

APPENDIX F: Parent Permission Form – Children 10-17 years old

You have just consented to participate in the Family Options Study. At this time, we would like to ask your permission for your child or children to participate in the study as well. In the past, they may have participated in the study by taking part in games, activities or short interviews.

Purpose of Child Data Collection
This study will look at the effects that different housing and services have on the health and well-being of children who have experienced homelessness. The study involves a short interview with children 10 to 17 years of age.

The interview should last about 30 minutes. The interview will cover various topics such as school, life events, and how they feel about themselves, and their relationship with a caregiver. You should know that all youth will be asked some sensitive questions. Some of the questions will be about substance use. Your child(ren) may find some of these questions personal or embarrassing. We will try to make sure your child(ren) is/are comfortable during the interview.

We will tell your child(ren) that you gave us permission to talk with them. We will ask your child(ren) if they want to do the voluntary interview and tell them that no one will see their answers, including you. We will remind your child(ren) that they can choose not to answer a question and that they can stop the interview at any time. If you or your child(ren) choose not to participate there will be no penalty or loss of benefits. We do ask that you not be present in the room nor on the phone as your child(ren) participates in the interview to ensure privacy.

In appreciation for the time your child(ren) spends participating in this study we will email you a $25 gift card for each child that participates.

Does my child(ren) have to participate?

Your child(ren)’s participation in this study is completely voluntary. Your child(ren) can choose not to answer any question. Your child(ren) can stop the interview at any time. If you decide that you do not want your child(ren) to participate in the study that is okay. Any housing or other assistance you may receive will not be affected if your child(ren) does not participate. You will still be part of the original study that you enrolled in approximately 12 years ago. There are no financial costs to you or your child for your child(ren)’s participation in the study.

If I sign this parental permission form, to what else am I agreeing?
If you sign this parental permission form, you give your permission for your child(ren) to participate in this study. Please refer to the adult consent form that you just signed for more information about the other types of data we will collect about your child.

CONFIDENTIALITY: Who will see the information provided?

• All information your child(ren) provides in confidential. Any information that the researchers collect about your child(ren) will be kept confidential. Special efforts have been taken to protect your child(ren)’s privacy and ensure that any confidential information that they share is not accidentally disclosed. If someone is at risk of harm, we may have to report it to the appropriate authorities. Please refer to the PRA Burden Statement and Privacy Act Statement included in the notification letter we sent you to learn more about how we will protect your information.

• Information collected as part of this study will be used for research purposes only.

• This study has a special certificate from the U.S. government. This certificate adds extra protection for the research information that identifies your child(ren). This certificate does not mean the government approves or disapproves of this study. It says that the research team does not have to identify you or your child(ren) or provide any information about you or your child(ren), even if a court asks them to. Your child(ren)’s information will be protected to the extended allowed under the law as part of the Privacy Act. (This means, for example, that the researchers may need to notify someone if keeping the information confidential could put your child(ren) or others at risk of harm.)

• Your child(ren)’s name will never be used in any report. Reports for this study will only show summaries, no names or individual identifying information will ever be used in any research report. Only the following people will see your child(ren)’s personal identifiers: (1) the interviewer conducting the survey and (2) a small number of Abt research staff authorized to work on the Family Options Study.¹

Are there any risks to your child(ren) if they participate in this study?
There are minimal risks to your child(ren) from participating in these activities. Remember, your child(ren)’s participation in these activities is voluntary. Interviewers will help ensure that your child(ren) is comfortable. They will remind your child(ren) that they can decide not to answer any of the questions.

The study has strict procedures in place to protect the information that you provide. However, there is some risk that your child(ren)’s information could be released inadvertently to people other than the researchers completing the study. If that were to happen, we would contact you to let you know that this occurred.

Questions about Participation
If you have questions regarding the study, please contact the Survey Director Ms. Brenda Rodriguez at 617-XXX-XXXX. You may also contact the Abt Associates Project Director Ms. Lauren Dunton at 301-XXX-XXXX. (These are not toll-free numbers.) You may also call the study toll-free line at 1-800-XXX-XXXX.

This study has been reviewed by Abt Associates Institutional Review Board. If you have any questions about your child(ren)’s rights as a participate in this study, you can call the IRB at (877) 520-6835.

Statement of Permission
Before giving my permission by signing this form, I confirm that I have read this form or had it read to me. The information in this form has also been explained to me. I have had the opportunity to ask questions. I understand the information presented in this form. I understand that my child(ren)’s participation is voluntary, and they can ask to be withdrawn from the study at any time. I understand that even though I give my permission for my child(ren) to participate, my child(ren) can still decide not to participate in the research. I also understand that there will be no penalty if me or my child(ren) refuse to participate in this research. I understand I will be given a signed copy of this permission form to keep.

I voluntarily agree to give permission for my child(ren) to take part in this study of program for families who experienced homelessness and child outcomes.

Participant Study ID: ____________________________

Parent or Legal Guardian’s Name – PLEASE PRINT

Signature of Parent or Legal Guardian Date

Focal Child Name 1 (First and Last Name) Child’s Date of Birth

Focal Child Name 2 (First and Last Name) Child’s Date of Birth

COMPLETE IF INTERVIEW COMPLETED BY PHONE:
Verbal Consent Obtained: YES NO

____________________________________________
Name of Interviewer

____________________________________________ ________________________

Signature of Interviewer Date

1 HUD will make this data available to other people to maximize the benefits of this research. HUD will make two versions of the data available. Neither version of the data will include any identifying information about you. Only HUD-approved researchers will be able to use the first version of the data. HUD will require anyone who they provide access to these data to commit to protecting the data, and to presenting results in summary form only. The other version of the data will be available to the public. There will be no restrictions on who can use the public version of the data. Because there are no limits on who could use the public data, HUD will take additional steps to make sure your identity is protected. They will do this by including more summarized information. For example, rather than showing that a study participant is 30 years old it would show that the study participant is between 25 and 35 years old.