Parent Component

RI-CHA-2007-06-29

Working Toward Wellness

Parent Consent Form for Children

A little over a year ago, you spoke with someone from United Behavioral Health about a project called Working Toward Wellness. The purpose of the study is to learn how to help people who might be feeling depressed. At the time you enrolled in the study, you may have become eligible for extra services, or you may have been told about services available to you in your community. We also mentioned that we may be contacting you for future interviews.

What we are studying

We are interested in asking you some questions about your experiences as a parent and about your child(ren). We will ask you about your child(ren)’s development, your relationship with your child(ren), their school activities, their general health, your child(ren)’s child care experiences (if applicable), and questions about your parenting practices. You will receive $30 for your time, which is in addition to the $20 for the survey which asks you questions about yourself. Therefore, if you complete both portions, you will receive a total of $50.

In addition to asking you some questions, we have selected up to two children in each family to understand more about them and their experiences. For younger children, we will play some games with them to understand their skills and give them a test of their understanding of emotions and their language skills. For older children, we will ask them about their schooling, behavior, activities and interests. The time with each child will be about forty-five minutes, depending on how old they are.

Giving consent means that you will allow us to obtain state and United Behavioral Health records regarding your child(ren)’s use of Medicaid and medical services (i.e. doctor’s visits, medications obtained through prescriptions, etc.). We ask you to give us your child(ren)’s social security numbers so we can obtain these records.

Benefits and risks of participation

There are no known risks to completing the interview, or the games and other assessments. If you agree to allow us to talk to your child(ren), we will briefly explain the study to the child so he or she can decide about participating. Your older child(ren) will receive a $20 gift certificate to show our appreciation for their participation. Your younger child(ren) will receive a toy as a gift that is valued at $10.

Participation is voluntary

The results of this study can help us understand better how to help people who might be depressed, along with their families and their children. However, it is important that you understand that participation in this study is completely voluntary for you and your child(ren). You and your child(ren) may refuse to answer any questions and still remain in the study. You and your child(ren) may also stop the interview at any time without penalty. Your decision will not affect any services or benefits you might receive now or in the future.

Protecting your information

All the information you and your child(ren) provide will be kept confidential. All study staff are trained to protect privacy and sign a privacy pledge. Your answers will be recorded with an identification number and your names will be kept in a location separate from your answers. No reports will describe you in a way that would allow you to be identified either.

We will do everything we can to keep others from learning about your participation in the research. We have a Confidentiality Certificate from the U.S. government that adds special protection for the research information that identifies you. It says we do not have to identify you, even under a court order or subpoena. You should know, however, that we may tell someone if harm to you, harm to others, or child abuse becomes a concern (this report would not be based on any information that comes out of any of your saliva samples). Also, the federal agency that pays for this study may see your information in an audit, but it too will protect your privacy. This Certificate does not mean the government approves or disapproves of our project.

If you have questions at any time during the study, please call Francisca Azocar or Kathy Sweet at United Behavior Health toll-free at (800) 207-0084. You can also call David Butler or Pamela Morris at MDRC using the toll-free number (800) 221-3165.

Consent for Myself

By my signature, I agree to be interviewed about my experiences as a parent and about my child(ren). I understand that all my responses will remain confidential.

(RESPONDENT’S NAME)

(SIGNATURE OF RESPONDENT)

(INTERVIEWER'S SIGNATURE) (DATE)

Consent for Children

By my signature, I agree to allow the following child(ren) to participate in the youth interview, games, and/or assessments as described above. I also agree to allow the disclosure of their medical records. I understand that the child(ren)'s answers will remain confidential. A copy of the study description given to my child(ren) will be provided to me.

_______-______-__________

(CHILD'S NAME) (SSN)

_______-______-__________

(CHILD'S NAME) (SSN)

(SIGNATURE OF PRIMARY CAREGIVER)

(INTERVIEWER'S SIGNATURE) (DATE)

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