Washoe Consent_8_10_12

Introduction and PURPOSE OF STUDY

The U. S. Department of Health and Human Services has hired Westat, a research company, to study the services Washoe County Department of Social Services gives to families. The study will help us learn which services help children stay out of foster care or leave foster care sooner. We want your help in finding out which services work better. You do not have to be in the study. You can stop being in the study at any time. Your choice will not affect your case or the services that you and your family get.

Procedures

Collection and use of assessment information:

Washoe County investigated your family’s case. As a result, the County requires your family to get services. Washoe County assigned your family (using a random process like a coin flip) to get one of two types of services that are meant to help you. With either service you get from Washoe County, a caseworker will make regular visits to your home, refer you to needed services, and check on how your family is doing. While you are getting these services, Westat will be studying which services work better at helping families. Part of the study includes collecting information about you and your family.

We are asking you to agree to let Westat collect information about you and your family for the study. If you agree to be in the study, Westat will collect the information and use it in the study. If you do not want to be in the study, a Washoe County staff member may still collect this information from you, depending on the type of services the County assigns you. But, we will not use your assessment information in the study.

The study will ask questions about you and your family. If you agree to be in the study, Westat will collect this information several times during your case: (1) at the start of services, (2) every 6 months until you stop getting services, and (3) and at the end of your services or by April 2015, whichever comes first.

A Westat researcher will visit you at home at a time that is best for you. During that visit, you will use a computer to answer questions. You can ask questions at any time. You can also skip questions that you do not want to answer. The questions will take about 90 minutes to answer. There are no right and wrong answers. We ask that you answer the questions honestly.

Combining assessment information with Washoe County DSS client records:

In addition, the study will combine the information from questions we ask you with the client records that Washoe County collects as part of their regular services. These records have information about you and your family, about the services you receive from Washoe County, and your case progress. We are asking you to agree to let us combine the assessment information with your client records.

RISKS

We do not expect being in the study has any risks. If some of the questions make you feel upset or sad, you can talk with your caseworker. You can also skip questions that you do not want to answer.

BENEFITS

There are no direct benefits to being in the study. But, taking part will help Washoe County come up with better ways to serve families and children.

Participant and Data Privacy

We will keep your information private according to the requirements of the Privacy Act of 197, (Public Law 93-579). We will use your information for research purposes only. Your caseworker may see summary information from your answers. We will not include information that identifies you or your family in any reports.

To help us protect your information, we received a Certificate of Confidentiality from the U. S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding, under a court order or subpoena. However, we will in all cases take necessary action, including reporting to authorities, to prevent harm to yourself or others. This includes reporting suspected child abuse or neglect.

To make sure that Westat researchers are collecting the data right, another Westat researcher may ask to sit in on the visit. We will ask you ahead of time so you can decide if the other researcher can come or not.

Signature

Signing this form means that you read or listened to someone read this form to you, that you understand what it says, and that you agree to be in this study. You will receive a copy of the signed consent form.

For each statement below, check the “Yes” box if you want to take part in the study. Check the “No” box if you do not want to take part in the study. Then, sign your name and give this form to the Westat researcher.

I agree to the collection and use of my assessment information by Westat in the described study.
Yes, I agree to let Westat collect and use my assessment data in this study.		No, I do not agree to let Westat collect and use my assessment data in this study. I understand that a Washoe County staff member may still collect this information from me.
I agree to have Westat combine my assessment information with the Washoe County DSS client records for this study.
Yes, I agree to let Westat combine my client records with my assessment information for this study.		No, I do not agree to let Westat combine my client records with my assessment information.

___________________________________ Participant’s Signature (Parent/Caregiver)

_____________________________________

Print Name

___________________________________

Date

CONTACT

For questions about the study, please contact:

Allison Meisch, Westat Study Contact

1-800-WESTAT1 (937-8281), x2820

AllisonMeisch@westat.com

For questions about your rights as a participant in this study, contact:

The Westat Institutional Review Board (IRB) Administrator, 1-800-WESTAT1 (937-8281), x8828

Date of IRB approval of this consent: 5/29/12

Expiration date of IRB approval of this consent: 3/13

OMB NO:

EXPIRATION DATE:

THE PAPERWORK REDUCTION ACT OF 1995: Public reporting burden for this collection of information is estimated to average 90 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.

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