Apprendix B

Appendix B

Parental Permission Form
Purpose of the Evaluation
Abt Associates, Inc., a private research company is conducting a nation wide study of
mentoring programs, including the program to which your child is applying. The study is
being sponsored by a federal government agency, the Family and Youth Services Bureau
in the U.S. Department of Health and Human Services. We are asking about 625 kids
across the country to participate in the study. In addition to asking for your permission,
we will also be asking your child to agree to be in the study.
What it means for your child to participate
There are two questionnaires that your child will be asked to fill out. If you give us
permission to include your child in the study, then your child will fill out one
questionnaire when he or she enrolls in the program. Your child does not have to
complete the survey to get into the program. Your child’s specific answers to the
questionnaire will not affect his or her eligibility for program services. We will ask your
child to complete another, similar questionnaire in about one year.
The questionnaires will ask your child about a variety of topics. Kids will be asked some
basic questions about their families and the relationships they have with different family
members. Other questions focus on kid’s feelings and behaviors that may occur at
school, at home, or in the neighborhood. Topics may include school disciplinary
problems, violence, and drug use. Children will also be asked some questions about
their mentors and how regularly they meet.
In about nine months, we will send your child a letter reminding him or her about the
study and the second questionnaire, and offering him or her $15 to confirm his or her
telephone number or tell us if the number has changed. After completing the second
questionnaire, your child will receive a gift certificate for $20. Additionally, $25 will be
offered to you for ensuring that your child is available for the interview. Taking part in
the follow-up questionnaire is entirely up to you and your child, and your decisions will
not affect any other service for which you or your child may be eligible. Also, your child
does not have answer every question and can stop the questionnaire at any time.
Risks and Benefits
There are small risks to your child for being in the study. Some of the questions ask
about behaviors that may be personal or uncomfortable, and your child may choose not
to answer these questions. The other possible risk is that someone outside of the
program or the study may see your child’s answers. However, we take several steps to
make sure that your child’s participation in the study and responses will be kept private.

Confidentiality
Abt Associates follows strict rules to protect your child’s privacy and the confidentiality of
any information that your child provides to the study. Your child’s name will not appear
in any reports produced for this study. The study team will not share your child’s
answers with mentoring program staff, mentors, employers, teachers, friends, and
family. It is possible that if another study is conducted in the future, the Family and
Youth Services Bureau and/or another researcher may use your child’s contact
information and/or questionnaire responses to conduct this study with Mentoring
Children of Prisoner Program participants.
Your child’s name will be replaced with an identification number for the purpose of this
study. All questionnaire information will be entered in a database and stored in a secure
computer network. Paper copies of questionnaires will be kept in secure files and
locked.
We have obtained a Confidentiality Certificate from the US Department of Health and
Human Services (DHHS) to protect the researchers from being forced, even by court
order or subpoena, to identify you or your child. (The Certificate does not imply
approval or disapproval of the project by the Secretary of DHHS. It adds special
protection for the research information about you and your child.) You should know,
however, that researchers may provide information to appropriate individuals or
agencies if harm to you, harm to others, or child abuse or child neglect becomes a
concern. In addition, the federal agency funding this research may see your information
if it audits us.
Questions
If you have any questions about the study or the questionnaires please call the study’s
toll free information line at 877-227-3107. Questions about study participants’ rights
should be addressed to Ms. Marianne Beauregard at Abt Associates, at 617-349-2852
(toll call).

Institutional Review Board
Approval Date: 4/23/07
Expiration Date: 4/23/08

I have read and understood the description of the Evaluation of the Mentoring Children of Prisoners
Program. I agree to allow the researchers conducting this research to collect baseline and follow-up
information from my child and contact me or my child for future follow-ups. I understand that the
information will be used ONLY for the purpose of the study and will be kept strictly confidential.
Print Child’s Name:
_____________________________________________________________________________________
First
Last
Print Your Name:
___________________________________________________________________________________________
First
Last
Your Signature: _____________________________________________ Date: __________________
Mentoring Children of Prisoners Program Name:
_________________________________________________________________
Your Contact Information (Please Print)
Address: ____________________________________________________________________________________
____________________________________________________________________________________
Phone Number: ______________________________________
It would be very helpful if you please could also provide the names of 1-2 people who would be able to provide us with
your new contact information if you were to move within the next year. A researcher would only explain to this person
that you are involved with a “research project” but would give no further details about the study.
Person #1
Name: _____________________________________________________________________________________
First
Last
Address: ____________________________________________________________________________________
____________________________________________________________________________________
Phone Number: ______________________________________
Person #2
Name: _____________________________________________________________________________________
First
Last
Address: ____________________________________________________________________________________
____________________________________________________________________________________
Phone Number: ______________________________________

Child Assent Form
A private research company, Abt Associates Inc., is doing a study about the Mentoring
program you are applying for. The study is supported by a U.S. government agency,
the Family and Youth Services Bureau. Hundreds of kids like you will be in the study.
Although we are also asking for your parents’ or guardians’ permission, we want to tell
you about the study and make sure that you agree to be in it.
What does it mean to be in the Study?
If you agree to be in the study, you will be asked to answer some questions two times.
The first time happens when you sign up for this program. The second time is in about
one year, when someone from the study will telephone your home to ask you some
questions. There are no right or wrong answers to the questions. Some of the
questions may make you uncomfortable because they ask about some bad behavior, like
fighting or drinking alcohol, or about other personal stuff. All of your answers will be
kept private. Nobody outside of the study will ever see your answers, and you don’t
have to answer all of the questions if you don’t want to. The only time the study team
would tell someone else about your answers is if we learned that someone was hurting
you and you needed help. We promise that:
•

YOUR ANSWERS TO ANY QUESTIONS WILL NOT COUNT TOWARD GETTING
INTO THIS PROGRAM.

•

NO ONE WILL SEE YOUR ANSWERS OTHER THAN THE PEOPLE DOING THE
STUDY. YOUR PARENTS, FRIENDS, TEACHERS, MENTORS, AND OTHER PEOPLE
YOU KNOW WILL NOT SEE THE ANSWERS.

•

IF YOU COMPLETE THE QUESTIONS THE SECOND TIME OVER THE TELEPHONE,
WE WILL SEND YOU A GIFT CERTIFICATE FOR $20.

Please check one of the sentences below and sign your name, telling us whether or not
you will be in the study. If you do not want to be in the study, nothing bad will happen
to you.
____YES, I WILL BE IN THE STUDY. My answers will be used for research and will
never be given to my parents/guardian, my school, mentor, teachers, friends or anyone
else.
____NO, I DO NOT WANT TO BE IN THE STUDY.
________________________
Print Name

______________________
Sign Name
Institutional Review Board
Approval Date: 04/23/07
Expiration Date: 04/22/08