0 Appendix F3

OMB Control No:
Expiration Date:

5TH GRADE FOLLOW-UP OF THE EARLY HEAD START STUDY
PARENT CONSENT TO BE VIDEOTAPED
As part of the 5th Grade Follow-up of the Early Head Start study, the research team will use a video camera to
record you and your child working on a task together.
The activities filmed by the video camera are strictly confidential. The videotapes may be edited and copies
will be made for research purposes only.
Even though images of you and your child, your voices, and your first names will be on the videotape,
identifying information such as your full names and address will not be given to anyone unless it is required by
law. The research staff who will see the videotape will sign a promise of confidentiality that says that they
agree with these rules.
Your participation in this study and the videotaping is voluntary. You may stop participating in the videotaped
activities at any time. You will not receive any additional compensation for being videotaped.
Please sign this form if you agree to allow the voices and images of yourself and your child to be
videotaped in your child’s home and the videotapes to be used for research purposes only.

Name of Participant (Printed)

Signature of Participant

Date

Name of Person Administering this Form (Printed)

Signature of Person Administering this Form

Prepared by Mathematica Policy Research, Inc.
(7-1-06)

Date

Page 1

5TH GRADE FOLLOW-UP OF THE EARLY HEAD START STUDY
PARENT CONSENT FOR VIDEO TO BE USED FOR ADDITIONAL
RESEARCH AND EDUCATIONAL USES
By signing this additional form, you will give permission for the videotape to be reproduced and shown for
educational purposes at conferences and workshops, and to be used for training researchers and
interviewers with the understanding that no identifying information will be used. You will not receive any
additional compensation for giving this permission.

Name of Participant (Printed)

Signature of Participant

Date

Name of Person Administering this Form (Printed)

Signature of Person Administering this Form

Prepared by Mathematica Policy Research, Inc.
(7-1-06)

Date

Page 2