Head of Household Consent

Attachment D: HEAD OF HOUSEHOLD CONSENT FORM

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

INFORMATION AND CONSENT FORM FOR DEPENDENT RESPONDENT

PLEASE NOTE THIS CONSENT FORM WILL BE READ TO THE PARENT/GUARDIAN. The head of household is an adult individual who resides in this household and is responsible for, or shares responsibility for, the finances and decision making for keeping up the home.

INTRODUCTION

Hello, my name is _____. I am a survey interviewer from NORC at the University of Chicago for a research study supported by the [BALTIMORE CITY HEALTH DEPARTMENT/GARRETT COUNTY HEALTH DEPARTMENT] in partnership with the U.S. Centers for Disease control and Prevention. We are conducting a survey across [Baltimore/Garrett County] to learn about young peoples’ health, educational, and life experiences.

HOH CONSENT FOR HOUSEHOLD QUESTIONNAIRE

As part of the survey, I would like to ask you some questions about your household. This short survey will also help us to learn more about health, educational, and life experiences for young people in your community. There is little or no risk to either you or your family for participating in this survey. There are no consequences for not participating. There are no direct benefits to you for participating in this survey. You will not receive anything, such as money or gifts, for being in this survey; however, the youth respondent will receive [INCENTIVE AMOUNT] as an incentive for participating in the main questionnaire.

Your household has been randomly chosen to participate in the survey. I want to assure you that all of your answers will be kept strictly confidential, and your name and address will not be connected with any of your responses. You have the right to stop the interview at any time, or to skip any questions that you don’t want to answer. There are no ‘Right’ or ‘Wrong’ answers.

Your participation is completely voluntary but your experiences could be very helpful to other people in [BALTIMORE/GARRETT COUNTY].

Would it be alright for me to ask you some questions? The questions should take only 10-15 minutes to complete.

Does not agree to answer questions. (SKIP TO THE QUESTION ABOUT WHETHER THE HOH IS THE PARENT/GUARDIAN IN GRAY BELOW)

agrees to answer the head of household questionnaire.

Do you have any questions?

For any further concerns about your rights in this survey or the procedures I am following, you may contact: [XXXXXXXXXXXXXXX FROM BALTIMORE CITY HEALTH DEPARTMENT AT (404)-XXX-XXXX/GARRETT COUNTY HEALTH DEPARTMENT AT (XXX)-XXX-XXXX] or XXXXXXXXXX from NORC at the University of Chicago at (301) XXX-XXXX, who are prepared to address your concerns or refer you to someone who can. Please feel free to write down this information for future reference.

Are you the parent/guardian of the selected respondent?

YES, HOH IS THE PARENT/GUARDIAN OF SELECTED RESPONDENT (SKIP THE GRAY INTRODUCTION BOX AND CONTINUE TO THE PARENT/GUARDIAN PERMISSION SECTION)

NO, THE HOH IS NOT THE PARENT/GUARDIAN OF THE SELECTED RESPONDENT

1. ADMINISTER HOUSEHOLD QUESTIONNAIRE WITH HOH

2. ASK TO SPEAK TO THE PARENT/GUARDIAN OF THE SELECTED RESPONDENT

3. READ THE GRAY INTRODUCTION BOX TO THE PARENT/GUARDIAN AND THEN CONTINUE TO THE PARENT/GUARDIAN PERMISSION SECTION)

INTRODUCTION

Hello, my name is _____. I am a survey interviewer from NORC at the University of Chicago for a research study supported by [BALTIMORE CITY HEALTH DEPARTMENT/GARRETT COUNTY HEALTH DEPARTMENT] Partnership with the U.S. Centers for Disease control and Prevention. We are conducting a survey in Baltimore to learn about young peoples’ health, educational, and life experiences.

PARENT/GUARDIAN PERMISSION

Would it be alright for me to ask the young person who has been selected from this household some questions about health, educational, and life experiences?

Topics include such things as experiences in school, access to food, health status, violence in the community, experiences accessing professional medical and social services, and their relationships with friends, family and community members. The goal of this survey is to improve health and education programs for young people in [BALTIMORE/GARRETT COUNTY]. The only potential risk is that some respondents might find certain questions to be sensitive.

NOTE WHETHER THE PARENT/GUARDIANAGREES TO ALLOW YOU TO SPEAK WITH THE RESPONDENT:

Does not agree to allow you to speak to the RESPONDENT

agrees to Allow you to speak with the RESPONDENT

Name of Interviewer Obtaining Verbal

Consent:__________________________________________________

Date:___________________________________________

INFORMATION AND CONSENT FORM FOR HEADS OF HOUSEHOLD FOR PARTICIPATION IN HOUSEHOLD QUESTIONNAIRE WHERE RESPONDENT IS

NON-DEPENDANT

THIS INFORMATION FORM WILL BE READ TO THE PARTICIPATING HEAD OF HOUSEHOLD

Thank you for allowing me to talk to you and members of this household. As I mentioned earlier, I am a survey interviewer from NORC at the University of Chicago for a research study supported by the [Baltimore City/Garrett County Health Department] in partnership with the U.S. Centers for Disease Control and Prevention. We are conducting a survey across [Baltimore/Garrett County] to find out more about the health, educational, and life experiences of young people here. The goal of this survey research is to make health and education programs for young people in Baltimore better. (INTERVIEWER: IF THE HEAD OF HOUSEHOLD COMPLETED HH LISTING FORM WITH YOU THEN THERE IS NO NEED TO REPEAT THIS INFORMATION AND YOU CAN SKIP TO THE NEXT PARAGRAPH)

As part of the survey, we would like to ask you some questions about your household and some of the people in it. This short survey will also help us to learn more about health and education for young people in your community. There is little or no risk to either you or your family for participating in this survey. Some of the questions in the survey ask about access to water, toilet facilities and different household items. There are no consequences for not participating. There are no direct benefits to you from participating in this survey. You will not get anything, such as money or gifts, for being in this survey.

[IF THERE IS AN ELIGIBLE RESPONDENT]

As part of the study, I am going to invite the [young woman/young man] to answer some questions about health and life experiences for young people in Baltimore.

Would it be alright for me to ask you some questions? The questions should take only 10-15 minutes to complete.

Does not agree to answer HOUSEHOLD QUESTIONNAIRE. (THANK THE HEAD OF HOUSEHOLD FOR THEIR TIME AND END AND ASK TO SPEAK WITH THE NON-DEPENDENT RESPONDENT WHO WILL BE PARTICIPATING)

agrees to answer the head of household questionnaire.

Your household has been chosen by chance to participate in this survey. I want to assure you that all of your answers will be kept strictly confidential, and your name and address will not be connected with your survey responses. You have the right to stop the interview at any time, or to skip any questions that you don’t want to answer. There are no ‘Right’ or ‘Wrong’ answers.

Your participation is completely voluntary but your experiences could be very helpful to other people in Baltimore.

Do you have any questions?

For any further concerns about your rights in this survey or the procedures I am following, you may contact: [XXXXXXXXXXXXXXX from the Baltimore City Health Department at (410) XXX-XXXX/XXXXXXXX from Garrett County Health Department at (XXX) XXX-XXXX] or XXXXXXXXXX at NORC @ the University of Chicago at (301) XXX-XXXX, who are prepared to address your concerns or refer you to someone who can. Please feel free to write down this information for future reference.

Name of Interviewer Obtaining Verbal Consent:____________________________

Date:_________________________________________________________________