Kansas assent (assessment) 8-10-12

CHILD AND YOUTH ASSENT PROCEDURES

Kansas Intensive Permanency Project (KIPP)

Assessment Group

IRB # 19572

We would like to ask you to take part in a study called the Kansas Intensive Permanency Project (KIPP). The study is being done by the University Of Kansas School Of Social Welfare, in partnership with the four private foster care agencies in Kansas, (KVC Behavioral Healthcare, TFI Family Services, St. Francis Community Services, and Youthville).

Your parent(s) have agreed to participate in KIPP. This means that a person called a Data Liaison will meet with you and your family to ask questions and do 3 video recordings so that we can track how things are going for your family.

We are doing this study of KIPP to try to learn more about how we can help families with children in foster care get their children back home as quickly as possible and keep them at home.

Your decision to be in this study is voluntary. You do not have to participate if you do not want to. 

If you don’t feel like answering questions, you don’t have to, and you can stop participating at any time and that will be alright.

The people who work on the KIPP project with you will be happy to answer any questions you may have.

If you participate we will collect information about your parents and you. A person we call a Data Liaison will come to your parent’s home or meet with you in a private room of the foster care agency to collect this information. So, there are two things we will ask you to do to take part in KIPP:

1. We will want you to answer questions from the Data Liaison about things like how you’re doing at school, how you’re getting along with your parents and friends, what’s going well for you, and what things are difficult for you.

2. The Data Liaison will also ask you and your parent(s) to do something called a “Family Interaction Task (FIT).” For the FIT, you and your parent(s) will play several games together so we can watch to see what is easy for you as a family and what is harder. The FIT will be video recorded so we can take notes. It will take about 30 minutes.

If you participate you will receive a $10 gift card for each time, up to 3 times total. The project researchers may ask for your social security number in order to comply with federal and state tax and accounting regulations.

We will protect your privacy according to the requirements of the Privacy Act of 1974 (Public Law 93-579) to the fullest extent possible. The reports that come out of this project will not identify you or your family.

To help protect your privacy, the government has provided the research team a Certificate of Confidentiality. With this Certificate, we do not have to tell people that you participated in the study or share with others any of the information that you tell us. However, if you tell us that someone has hurt you or that you want to hurt yourself or someone else, we will report this to the authorities.

Do you have any questions?

Do you want to take part in this project?

Saying “yes” means that you have decided to participate and that all your questions about the study have been answered. I will make a copy of this form and put it in your case file.

Child/Youth’s response:

☐ Yes

☐ No

  

_______________________________________                              ______________________________ 

Printed Name of Child/Youth                                                           Date 

Date of IRB approval of this consent: November 1, 2011, HSCL #19572

Expiration date of IRB approval of this consent: November 2, 2012

OMB No: FORTHCOMING

Date of OMB approval: FORTHCOMING

Expiration date of OMB approval: FORTHCOMING

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.