Appendix B_Informed Consent forms

OMB 0970-0288

CASE WORKER AND PARTNER AGENCY GROUP INTERVIEWS: INFORMED CONSENT FORM

We would like to include you in the Systems of Care national evaluation, which is intended to provide critical data regarding if and how well this type of approach can result in better outcomes for child welfare-involved children and families, especially in the areas of safety, permanency and well being. In addition, the process component of the evaluation will document important information about the conditions under which a system of care approach is effective in a child welfare population, and the types of activities that must be implemented for positive outcomes to result. In the paragraphs below we summarize the procedures of the evaluation, how we will maintain your confidentiality, and the risks and benefits involved in the evaluation.

Procedures: You are being asked to participate in a one-hour to 1.5-hour group interview with evaluation staff. The discussion will center on your experience with the Systems of Care initiative in your agency. To assess the extent to which change has occurred, we conducted two prior group interviews and will be conducting a group interview today.

Confidentiality: Before we get started, there are a few other issues for which you need to be aware. First, it is important that you know that your participation in this group is completely voluntary and that no one associated with your agency will know whether or not you complete it, including your supervisor or co-workers. Also, you may skip any questions you do not wish to answer or terminate your participation at any time, without consequence. However, because your input is invaluable in helping the evaluation team understand the types of changes that occur as a result of the Systems of Care initiative, we would like to ask that you consider answering each question. Also, if you give your consent, and all other participants consent as well, handwritten or typed notes and a tape recorder will be used to record your answers. Finally, if you do not wish to participate in this interview we can stop this process now, without any consequence to you or the initiative.

Confidentiality: While your supervisor may know that you are participating in this group today, the information gathered during it is strictly confidential and will be used for the purposes of this evaluation only. Your name will not appear on any transcript or material associated with this group, including the audio-tape. Instead, the audio-tape will be assigned a special code, as will each respondent on it. The tape and transcripts then will be kept in a locked file at Caliber, an ICF International Company, to which only the research team will have access, which includes your local evaluation team. It will not be available to anyone involved with the initiative, including your supervisor, regardless of the intent of the request.

As part of our agreement with the local evaluation team, Caliber, an ICF International Company, will be providing the raw data from this group to them. Your local team, however, is bound by the same confidentiality regulations as is the national evaluation team (i.e., the team conducting this group). Therefore, they are required to keep confidential the information they receive from the national team, and to report findings in summary form, only. To ensure compliance to these regulations, the national evaluation team has a signed agreement with the local evaluation team.

In addition, it is important that you agree to maintain the confidentiality of your colleagues. That is, we are asking that you not repeat anything you hear in this group today to anyone outside of it. While Caliber, an ICF International Company, can do its part to protect your confidentiality, without your commitment to do the same for your colleagues, we cannot ensure your protection.

Risks: Because this group focuses on your experiences with the Systems of Care initiative in your agency, there are minimal risks posed to you for participating in it. There is a slight chance, however, that your responses may be discussed outside of this room. So that each of you feels confident that your responses will be protected, it is important that you agree to maintain the confidentiality of the others in the room. In addition, we ask that you be respectful of your fellow group members. That means, that everyone has a right to speak and a right to their own opinion, and that each person in the group will respect the rights of other group members. The findings from this group and others like it will be aggregated both within and across sites, and used to inform future child welfare policies and practices. Although you will receive no direct benefit from participating in this group, your help will be greatly appreciated and will add to our knowledge base about what works in improving outcomes for child welfare-involved children and their families.

If you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF International Company ICF by e-mail, RCrowel@icfi.com or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703- 385-3200 or by e-mail, RCalderon@icfi.com.

I understand that I have been asked to participate in a group interview with my colleagues about my experiences with the Systems of Care initiative in my agency. I also understand that if I, and all other participants consent, the group will be audio taped. I understand that my privacy will be protected and any information I provide here today will be used for research purposes only. I also understand that I can terminate my participation or refuse to answer questions, at any time, without consequence. Finally, I can call Raymond Crowel at ICF International, or Robert Calderon, the IRB chairperson, should I have questions or concerns about this interview.

I give my informed consent to participate in this group. Yes______ No _______

I give my informed consent for this group to be audio-taped. Yes______ No _______

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

CW Survey INFORMED CONSENT

Caliber, an ICF International Company is conducting a national evaluation of the Systems of Care initiative in your community and in eight other communities nationwide. The Systems of Care initiative is a demonstration project that is being sponsored by the Children’s Bureau. The initiative was developed to improve outcomes for child-welfare involved children and families by building local infrastructure to support collaboration and systems change between local child and youth serving agencies.

You have been selected to participate in this survey because of your role in your child welfare agency. As part of the Systems of Care initiative, your agency is implementing several activities that seek to improve the way agencies work with families who experience child maltreatment. The attached survey is designed to capture changes in practices and policies that occur as a result of this initiative. The survey includes items pertaining to the mission of your agency, as well as its practice philosophy, and policies related to working with children and families. This survey was administered twice before and will be administered again here today to determine the extent to which change has occurred over time.

Before you get started, there are a few other issues of which you need to be aware. First, it is important that you know that your participation in this survey is completely voluntary and that no one in this agency will know whether or not you complete it. Also, you may skip any questions you do not wish to answer, without consequence to your employment status. However, because your input is invaluable in helping the evaluation team understand the types of changes that occur as a result of the Systems of Care initiative, we would like to ask that you consider answering each question.

The survey should take about 40 minutes to complete. To protect your privacy, do not write your name anywhere on the survey, and, once completed, a member of the local evaluation team will collect your survey. This same person also will be responsible for making sure the surveys are delivered to Caliber’s, an ICF International Company, office either by hand or through FedEx. We realize there are questions throughout the survey that ask about the practices and policies of your agency. In addition, there are questions at the end of the survey that ask about you specifically. Should you feel uncomfortable answering these questions, you can skip them. Again, please do not put your name on the survey. We want to ensure that your anonymity is protected and therefore do not want any connection made between your survey responses and your name. The consent forms will be kept in a secure location separate from the survey and your name in no way will be connected to your survey responses.

Again, because your input is invaluable in understanding how your agency operates and changes as a result of the Systems of Care initiative, we would like to ask that you consider answering each question.

As part of our agreement with the local evaluation team, Caliber, an ICF International Company, will be providing the raw data from this survey to them. Your local team, however, is bound by the same confidentiality and privacy regulations as the national evaluation team (i.e., the team conducting this survey). Therefore, they are required to keep confidential the information they receive from the national team, and to report findings in summary form only. To ensure compliance to these regulations, the national evaluation team has a signed agreement with the local evaluation team.

Thank you for your cooperation; your input will provide valuable information about the Systems of Care initiative and its affect on child-welfare agency policies and practices.

I understand that I have been asked to participate in a survey about my experiences with my child welfare agency and the Systems of Care initiative in my community. I also understand that this survey is completely anonymous and that I can terminate this survey at any time. Finally, if you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF International company by e-mail, RCrowel@icfi.com, or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703-385-3200 or by e-mail: RCalderon@icfi.com

I give my informed consent to participate in this survey. Yes____ No _____

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

FAMILY MEMBER INFORMED CONSENT FORMS FOR FOCUS GROUPS

We would like to include you in the Systems of Care national evaluation, which is intended to provide critical data regarding if and how well this type of approach can result in better outcomes for child welfare-involved children and families, especially in the areas of safety, permanency and well being. In the paragraphs below we summarize how we would like for you to be involved, how we will maintain your confidentiality, and the risks and benefits involved in participating in this focus group.

Procedures: You are being asked to participate in a 60-90 minute focus group with national evaluation staff . Participation in this focus group, is completely voluntary. You have the right to refuse to answer any question or stop participating in this group at any time, without any consequence to you. If you give your consent, handwritten notes and a tape recorder will be used to record your answers. The focus group will focus on your experience with the child welfare agency and the nature and type of services you have received as a result.

Confidentiality: While your [parent partner/mentor] may know that you are participating in this interview today, the information you give us is strictly confidential and will be used for research purposes only. Your name will not appear on any transcript or material associated with this interview, including the audio-tape. Instead, your name will be assigned a special code that will be kept in a locked file at Caliber/ICF Consulting, to which only the research team will have access. Records, including notes and audiotapes, will not be released to others, including anyone involved with your case, such as your caseworker, lawyer, your child’s guardian or foster parent, or anyone else with whom you may be involved as a result of your involvement with the child welfare agency.

You must understand one thing, however. If you disclose that you are in imminent danger, that is, are having thoughts of suicide or homicide, we will refer you to a crisis hotline that operates 24 hours a day, 7 days a week. The crisis hotline that we have selected for use in these cases is (to be determined). The crisis counselor at the hotline has been trained to talk with people in distress, and should be able to talk with you about your feelings of distress or thoughts of harming yourself or someone else. If necessary, we will ask that you call the hotline before you leave here today. In addition, if anything you tell us indicates that your child (ren) are in imminent danger or at risk, we will be required to call the child abuse hotline or your child’s caseworker. We will make every effort to support you, however, and get you the help that you need, while keeping your child safe.

Risks: Because this interview focuses on your experience with child welfare agency only, not the details of your case, there are minimal risks posed to you for participating in this interview. There is a slight chance your responses might be talked about outside of the focus group by other focus group participants, although everyone who agrees to participate in this group must agree to keep the identity of other participants private and not to discuss responses with anyone outside of this focus group. The [child welfare agency], has indicated verbally that they are in complete support of this project for the families that choose to participate in it. Therefore, you should feel confident that your participation poses very little risk to you or your children. Also, as outlined above, the evaluation team will take steps to ensure that the information you provide is confidential and that your identity is protected, except in those cases where you or your children are in imminent danger or at risk.

Benefits: You are being paid $35 in gift credits to participate in this focus group. The information you give us today will help us understand the experiences of families in the child welfare system and to identify ways to improve their experiences. We appreciate both your willingness to participate and your opinions. They will be invaluable to this study.

If you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF international Company ICF by e-mail, RCrowel@icfi.com or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703- 385-3200 or by e-mail: RCalderon@icfi.com.

I understand that I have been asked to participate in a focus group. I also understand that if I, and all other participants consent, the focus group will be audio taped. I further understand that my privacy will be protected and any information I provide here today will be kept confidential and used for research purposes, only. I also understand that I can stop participating in this group at any time, without consequence, and that there is minimal risk to me in agreeing to participate, except in situations where I report that I or my child may be in imminent danger or at risk. Finally, I can call someone at Caliber/ICF Consulting, including the IRB chairperson, should I have questions.

I give my informed consent to participate in this focus group. Yes______ No _______

I give my informed consent for this focus group to be audio-taped. Yes______ No _______

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

STAKEHOLDER INTERVIEWS: INFORMED CONSENT FORM

We would like to include you in the Systems of Care national evaluation, which is intended to provide critical data regarding if and how well this type of approach can result in better outcomes for child welfare-involved children and families, especially in the areas of safety, permanency and well being. In addition, the process component of the evaluation will document important information about the conditions under which a systems of care approach is effective in a child welfare population, and the types of activities that must be implemented for positive outcomes to result. In the paragraphs below we summarize the participation procedures, including how we will maintain your confidentiality, and the risks and benefits of your participation.

Procedures: You are being asked to participate in a 45-minute to one-hour interview with evaluation staff. The discussion will center on your experience with the systems of care initiative in your community. To assess the extent to which change has occurred, we administered this interview on three prior occasions and this will be our last administration.

Before we get started, there are a few other issues of which you need to be aware. First, it is important that you know that your participation in this interview is completely voluntary and that no one associated with the Systems of Care initiative will know whether or not you complete it. Also, you may skip any questions you do not wish to answer or terminate your participation at any time, without consequence. However, because your input is invaluable in helping the evaluation team understand the types of changes that occur as a result of the Systems of Care initiative, we would like to ask that you consider answering each question. Also, if you give your consent, and all other participants consent as well, handwritten notes and a tape recorder will be used to record your answers. Finally, if you do not wish to participate in this interview we can stop this process now without any consequence to you or the initiative.

Confidentiality: The information gathered during this interview is strictly confidential and will be used for scientific purposes only. Your name will not appear on any transcript or material associated with this interview, including the audio-tape. Instead, your name will be assigned a special code that will be kept in a locked file at Caliber, an ICF International Company to which only the research team will have access, which includes your local evaluation team. It will not be available to anyone involved with the initiative, including the project director or other stakeholders, regardless of the intent of the request.

As part of our agreement with the local evaluation team, Caliber, an ICF International Company will be providing the raw data from this interview to them. Your local team, however, is bound by the same confidentiality regulations as is the national evaluation team (i.e., the team conducting this survey). Therefore, they are required to keep confidential the information they receive from the national team, and to report findings in summary form, only. To ensure compliance to these regulations, the national evaluation team has a signed agreement with the local evaluation team.

Risks: Because this interview focuses on your experience with the systems of care initiative in your community, there are minimal risks posed to you by participating in it. In addition, because the information is confidential, it cannot be obtained by anyone that is not associated with the evaluation. This further reduces any risk to you in participating.

Benefits: The findings from this evaluation, including your interview, will be aggregated both within and across sites, and used to inform future child welfare policies and practices. Although you will receive no direct benefit from the interview or the evaluation, in general, your help will be greatly appreciated and will add to our knowledge base about what works in improving outcomes for child welfare-involved children and their families.

If you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF International Company by e-mail, RCrowel@icfi.com or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703-385-3200 or by e-mail: RCalderon@icfi.com.

I understand that I have been asked to participate in an interview about my experiences with the Systems of Care initiative in my community. I understand that my privacy will be protected and any information I provide here today will be used for research purposes, only. I also understand that I can terminate this interview at any time, without consequence. Finally, I can call Raymond Crowel at Caliber, an ICF International Company , or Robert Calderon, the IRB chairperson, should I have questions or concerns about this interview.

I give my informed consent to participate in this interview. Yes____ No _____

I give my informed consent for this interview to be audio-taped. Yes___ No_______

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

SUPERVISOR INTERVIEWS: INFORMED CONSENT FORM

We would like to include you in the Systems of Care national evaluation, which is intended to provide critical data regarding if and how well this type of approach can result in better outcomes for child welfare-involved children and families, especially in the areas of safety, permanency and well being. In addition, the process component of the evaluation will document important information about the conditions under which a systems of care approach is effective in a child welfare population, and the types of activities that must be implemented for positive outcomes to result. In the paragraphs below we summarize the procedures of the evaluation, how we will maintain your confidentiality, and the risks and benefits involved in the evaluation.

Procedures:

You are being asked to participate in a one-hour to 1.5-hour interview with evaluation staff. The discussion will center on your experience with the Systems of Care initiative in your agency. To assess the extent to which change has occurred, we administered this interview on three prior occasions and this will be our last administration.

Before we get started, there are a few other issues of which you need to be aware. First, it is important that you know that your participation in this interview is completely voluntary and that no one associated with your agency will know whether or not you complete it, including your supervisor or co-workers. Also, you may skip any questions you do not wish to answer or terminate your participation at any time, without consequence. However, because your input is invaluable in helping the evaluation team understand the types of changes that occur as a result of the Systems of Care initiative, we would like to ask that you consider answering each question. Also, if you give your consent, and all other participants consent as well, handwritten or typed notes and a tape recorder will be used to record your answers. Finally, if you do not wish to participate in this interview we can stop this process now, without any consequence to you or the initiative.

Confidentiality: While your supervisor may know that you are participating in this interview today, the information gathered during this interview is strictly confidential and will be used for the purposes of this evaluation, only. Your name will not appear on any transcript or material associated with this interview, including the audio-tape. Instead, your name will be assigned a special code that will be kept in a locked file at Caliber, an ICF International Company, to which only the research team will have access, which includes your local evaluation team. It will not be available to anyone involved with the initiative, including your supervisor, regardless of the intent of the request.

As part of our agreement with the local evaluation team, Caliber, an ICF International Company, will be providing the raw data from this interview to them. Your local team, however, is bound by the same confidentiality regulations as is the national evaluation team (i.e., the team conducting this survey). Therefore, they are required to keep confidential the information they receive from the national team, and to report findings in summary form, only. To ensure compliance with these regulations, the national evaluation team has a signed agreement with the local evaluation team.

Risks: Because this interview focuses on your experience with the systems of care initiative in your agency, there are minimal risks posed to you for participating in it. In addition, because the information is confidential, it cannot be obtained by anyone that is not associated with the evaluation. This further reduces any risk to you in participating. In addition, the administration of this agency has indicated verbally that they are in complete support of this evaluation, including having the staff participate in data collection efforts. The administration also understands that the information gathered will be kept confidential and is not available to them, regardless of the nature of any request.

Benefits: The findings from this evaluation, including your interview, will be aggregated both within and across sites, and used to inform future child welfare policies and practices. Although you will receive no direct benefit from the interview or the evaluation, in general, your help will be greatly appreciated and will add to our knowledge base about what works in improving outcomes for child welfare-involved children and their families.

If you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF international Company ICF by e-mail, RCrowel@icfi.com or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703- 385-3200 or by e-mail: RCalderon@icfi.com.

I understand that I have been asked to participate in an interview about my experiences with the Systems of Care initiative in my agency. I understand that my privacy will be protected and any information I provide here today will be used for research purposes, only. I also understand that I can refuse to answer certain questions or terminate this interview at any time, without consequence. Finally, I can call Raymond Crowel at Caliber, an ICF International Company, or Robert Calderon, the IRB chairperson, should I have questions or concerns about this interview.

I give my informed consent to participate in this interview. Yes____ No _____

I give my informed consent for this interview to be audio-taped. Yes____ No ____

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

TECHNICAL ASSISTANCE GROUP INTERVIEW: INFORMED CONSENT FORM

We would like to include you in the Systems of Care national evaluation, which is intended to provide critical data regarding if and how well this type of approach can result in better outcomes for child welfare-involved children and families, especially in the areas of safety, permanency and well being. In addition, the process component of the evaluation will document important information about the conditions under which a systems of care approach is effective in a child welfare population, and the types of activities that must be implemented for positive outcomes to result. In the paragraphs below we summarize the participation procedures, including how we will maintain your confidentiality, and the risks and benefits of your participation.

Procedures: You are being asked to participate in a one-hour to 1.5 hour group interview with evaluation staff. The discussion will center on your experiences with the technical assistance provided to your community throughout the systems of care initiative.

Before we get started, there are a few other issues of which you need to be aware. First, it is important that you know that your participation in this interview is completely voluntary. Also, you may skip any questions you do not wish to answer or terminate your participation at any time, without consequence. However, because your input is invaluable in helping the evaluation team understand the types of changes that occur as a result of the Systems of Care initiative, we would like to ask that you consider answering each question. Also, if you give your consent, and all other participants consent as well, handwritten notes and a tape recorder will be used to record your answers. Finally, if you do not wish to participate in this interview we can stop this process now without any consequence to you or the initiative.

Confidentiality: The information gathered during this interview is strictly confidential and will be used for scientific purposes only. Your name will not appear on any transcript or material associated with this interview, including the audio-tape. Instead, your name will be assigned a special code that will be kept in a locked file at Caliber, an ICF International Company, to which only the research team will have access, which includes your local evaluation team. It will not be available to anyone involved with the initiative, including the project director or other stakeholders, regardless of the intent of the request.

Risks: Because this interview focuses on your experience with technical assistance provided by the technical assistance center, there are minimal risks posed to you by participating in it. In addition, because the information is confidential, it cannot be obtained by anyone that is not associated with the evaluation. This further reduces any risk to you in participating.

Benefits: The findings from this evaluation, including your interview, will be aggregated across sites and used to inform future technical assistance efforts in child welfare systems change initatives.. Although you will receive no direct benefit from the interview or the evaluation, in general, your help will be greatly appreciated and will add to our knowledge base about what works in helping communities improve outcomes for child welfare-involved children and their families.

If you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF International Company by e-mail, RCrowel@icfi.com or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703-385-3200 or by e-mail: RCalderon@icfi.com.

I understand that I have been asked to participate in an interview about my experiences with the Systems of Care initiative in my community, and, in particular, the benefit of technical assistance in implementing Systems of Care. I understand that my privacy will be protected and any information I provide here today will be used for research purposes, only. I also understand that I can terminate this interview at any time, without consequence. Finally, I can call Raymond Crowel at Caliber, an ICF International Company , or Robert Calderon, the IRB chairperson, should I have questions or concerns about this interview.

I give my informed consent to participate in this interview. Yes____ No _____

I give my informed consent for this interview to be audio-taped. Yes___ No_______

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

TECHNICAL ASSISTANCE PARTICIPATION SURVEY: INFORMED CONSENT

Caliber, an ICF International Company, is conducting a national evaluation of the Systems of Care initiative in your community and in eight other communities nationwide. The Systems of Care initiative is a demonstration project that is being sponsored by the Children’s Bureau. The initiative was developed to improve outcomes for child-welfare involved children and families by building local infrastructure to support collaboration and systems change between local child and youth serving agencies.

You have been selected to participate in this survey because of your role in your child welfare agency and participation in technical assistance activities. As part of the Systems of Care initiative, your agency is implementing several activities that seek to improve the way agencies work with families who experience child maltreatment. The attached survey is designed to identify which technical assistance activities and resources your community received and how often your community participated in such efforts. This includes technical assistance activities/resources such as monthly technical assistance calls as well as peer-to-peer exchanges of information and resources.

Before you get started, there are a few other issues of which you need to be aware. First, it is important that you know that your participation in this survey is completely voluntary. Also, you may skip any questions you do not wish to answer, without consequence. However, because your input is invaluable in helping the evaluation team understand the types of changes that occur as a result of the Systems of Care initiative, we would like to ask that you consider answering each question.

The survey should take about 5 minutes to complete. Please do not write your name anywhere on the survey, and, once completed, along with your signed consent form, please send these materials via regular mail to your evaluation liaison. The consent forms will be kept in a secure location separate from the survey and your name in no way will be connected to your survey responses.

Again, because your input is invaluable in understanding how your agency operates and changes as a result of the Systems of Care initiative, we would like to ask that you consider answering each question.

Thank you for your cooperation; your input will provide valuable information about the Systems of Care initiative and its affect on child-welfare agency policies and practices.

I understand that I have been asked to participate in a survey about my experiences with technical assistance activities and resources throughout the course of the systems of care demonstration initiative. I also understand that this survey is confidential and that I can terminate this survey at any time. Finally, if you have any questions about this evaluation, please contact Raymond Crowel from Caliber, an ICF International company by e-mail, RCrowel@icfi.com, or by telephone at 703-385-3200. You also can contact Robert Calderon, the chairperson of Caliber’s Institutional Review Board (IRB) by telephone at 703-385-3200 or by e-mail: RCalderon@icfi.com

I give my informed consent to participate in this survey. Yes____ No _____

___________________________________________________________________

Signature of Participant Date

___________________________________________________________________

Signature of Project Staff Member Date

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