Grantee Case Study Protocol consent 7-19-12

OMB No:

EXPIRATION DATE:

Case Study Protocol

PERMANENCY INNOVATIONS INITIATIVE IMPLEMENATION CASE STUDY

INDIVIDUAL OR SMALL GROUP INTERVIEW

CONSENT FORM

Westat and its subcontractors, James Bell Associates, the School of Social Work of the University of North Carolina at Chapel Hill, Andrew Barclay Associates, and Ronna Cook Associates have been contracted by the Administration for Children and Families, Office of Planning, Research, and Evaluation (OPRE), to evaluate the Permanency Innovations Initiative (PII). This interview is designed to help assess progress towards implementation of PII initiatives, as well as to test the relationship between the achievement of implementation components and the attainment of full implementation. This interview/focus group will include questions about the planning, installation, and ongoing support of implementation drivers.

The individual or small group interview will last about 2 hours. Your participation is voluntary and you may discontinue your participation or choose not to answer certain questions at any point during the interview without risk of penalty. We anticipate no risk or harm by participating in this interview or focus group. The information collected will benefit the implementation of PII by tracking implementation progress, as well as provide information to the Federal government and other states regarding the impact of key implementation activities on the attainment of full implementation.

Everything you say today will be kept private to the extent allowed by law. If we see or are told that a child is being abused or neglected or is at risk of harm to self or others, we must disclose this information to the appropriate child abuse registry, as required by law. Information gathered today will be used to inform the cross-site implementation study and included in reports provided to the Children’s Bureau and OPRE during the duration of the project. Your name will not be used or appear in any reports. The information shared in the focus group will be reported in aggregate form only. To better assist researchers, the focus groups will be digitally recorded. The digital recordings will be used only so that researchers can correctly document statements made and will be erased after transcription. The digital recordings and transcripts will not be shared with anyone outside of the research team. The interview data collected will be stored on a secure server and will be accessible to select research team members for analysis and quality assurance purposes.

If you are participating in a small group interview, we ask that all group members respect the privacy of the sessions and not discuss “who said what” after the session is over. However, please be aware that this is the nature of groups and that this privacy can’t be absolutely guaranteed.

If you have any questions related to the interview itself, you may contact the survey manager, Leslie Cohen at lcohen@jbaassoc.com or 312-342-1397. If you have any general questions about the PII evaluation, you may contact the associate project director, George Gabel, at georgegabel@westat.com or 301-251-4223. If you have any questions regarding your rights as a participant, you may contact Sharon Zack, Westat Institutional Review Board (IRB) Administrator at 1-800-WESTAT1 (937-8281), x8828 or at SharonZack@westat.com.

If you agree to participate in the interview, please sign the statement below and take a copy of this form for your records.

Subject Statement:

I agree to participate in the interview that will include questions about key implementation activities. I understand what my participation in the interview involves and that I am free to end the discussion at any time and there will be no penalty for doing so.

SIGNATURE DATE

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.