Attachment b7: Rise Permanency Resource consent and INTERVIEW
PERMANENCY RESOURCE CONSENT FORM
to be printed on Westat Letterhead
Introduction and PURPOSE OF STUDY
Westat, a company hired by the U.S. Department of Health and Human Services, is studying special services being providing by a group working with the Los Angeles County Department of Children and Family Services (DCFS). The study is to find out if the special services help children stay out of foster care or leave foster care sooner. It will also help groups in your community come up with better ways to serve children and families.
We are asking you to take part in this study because you currently provide or will be providing care for a child receiving these special services. We will also ask the child if we can interview him or her.
You do not have to be in the study. You can stop being in the study at any time. Your choice will not affect the services that you and your family get.
Procedures
Collection and use of interview responses:
While you are getting the special services, Westat will be studying how much these services help children. Part of the study includes getting information about you, the child receiving special services, and how you feel about similar children.
A Westat worker is going to be asking you questions up to 2 different times. The first interview will be soon after you start participating in the special services from the group working with DCFS. The worker will meet with you again once more before services end.
A Westat worker will visit you at home at a time that is best for you. You can ask questions at any time. You can also skip questions that you do not want to answer. The questions will take about 1 hour to answer. There are no right and wrong answers. We just want you to be honest when you answer.
Studying your interview responses and foster care client records:
During the study Westat workers will review the information from questions we ask you and will also review information from foster care client records. These records have information that is already collected on children that are part of the foster care system. We are asking if you will agree to let us to study your answers together with the answers the child gives us and the information we get from the child’s foster care records. We will use this information only for the study.
DIFFERENT WAYS TO PARTICIPATE
There are no other ways to participate in the study other than completing the interviews.
Participant and Data Privacy
Only Westat workers will see your answers and we will keep your information private to the extent permitted by law. We will use your information only for research. We will not include information that identifies you or your family in reports we write.
To help us protect your information, we have a Certificate of Confidentiality from the U.S. Department of Health and Human Services. This Certificate means that no one can force us to share information that may identify you. This is true even in any court or legal proceeding, under a court order or subpoena. But we do have to take any needed 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 workers are collecting the data correctly, another Westat worker may ask to sit in on the interview. We will ask you ahead of time so you can decide if the other worker can come or not.
INCENTIVE FOR PARTICIPATING IN THE STUDY
You will receive a $20 gift card for taking part in each interview.
BENEFITS
There are no direct benefits to you. But by taking part, you will help groups in your community come up with better ways to serve children and families.
RISKS
We do not expect that there are any risks from your taking part in the study. If some of the questions make you feel upset or sad, you can talk with a caseworker. The worker also has a list of local mental health agencies that he or she can give you, if you ask. You can also skip questions that you do not want to answer or end the interview at any time.
treatment for injury related to this study
We do not expect that you will experience any injuries because of participating in the study. Therefore, no treatment will be available to address any injuries.
CONFLICT OF INTEREST
Westat has no financial or other relationships with your agency that will affect our role in conducting the study, including interpreting and reporting the study results.
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. Please provide your response to participating in the study by checking Yes or No in box A and B. Then, sign your name and give this form to the Westat researcher. You will receive a copy of the consent form.
A.. Do you agree that you have received a copy of the Research Participant’s Bill of Rights and agree to the collection and use of your interview answers in this study?
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B. Do you agree to have Westat study your interview answers with the interview answers provided by [insert child name] and the foster care records for this child’s case? |
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Participant’s Signature
_____________________________________
Print Name
___________________________________
Date
CONTACT
For questions about the study, please contact:
Jaymie Lorthridge, Westat Study Contact 1-800-WESTAT1 (937-8281), x5871
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You can learn more about your rights as a part of the study from the Research Participant’s Bill of Rights document. For questions about your rights as a participant in this study, contact: The Committee for the Protection of Human Subjects, (916) 326-3660.
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Date of IRB approval of this consent:
Expiration date of IRB approval of this consent:
RISE Identified Permanency Resource Interview
DATE: _______________________________________
EVALUATION id: ___________________________
INTERVIEWER: _______________________________________
interview task:
☐BASELINE
☐FOLLOW-UP
Permanent Connections Inventory Adult Version
You were identified by [INSERT YOUTH’S NAME] as a person who would be a permanency resource for him/her. A permanency resource is a person who is willing to provide a home for a youth and be a life-long source of emotional support.
[CIRCLE RESPONSE OPTION BELOW EACH QUESTION]
Would you say that you fit this definition?
1 = yes
0 = no [SKIP TO QUESTION 3]
What is the likelihood that you will remain as a dependable, supportive person throughout this young person’s life?
1 = not likely
2 = a little likely
3 = somewhat likely
4 = very likely
What is your relationship with [YOUTH’S NAME]?
1 = biological parent
2 = stepparent
3 = adoptive parent
4 = guardian
5 = relative (specify ________________________________)
6 = foster parent
7 = adult sibling
8
= fictive kin (e.g. close friend of family, relative of foster or
former foster family)
(specify ______________________________)
9 = mentor (e.g. teacher, coach)
10 = professional (e.g. CSW, counselor, CASA)
11= other (specify ______________________________________)
Now I would like to ask you about some characteristics of you and your family.
What is your gender? (If not obvious)
1 = male
2 = female
3 = transgender
4 = other
What is your age? ______
What is your race? (Select one or more.)
1 = American Indian/AK Native
2 = Asian
3 = Black/African American
4 = Hawaiian/Pacific Islander
5 = White
6 = Other (specify ______________________)
What is your ethnicity?
1 = Hispanic, Latino origin
0 = No Hispanic, Latino origin
How many people live in your household? _____
What is the highest level of education you have obtained?
1 = less than high school
2 = high school degree/or equivalent
3 = some college
4 = college
5 = graduate courses
6 = graduate degree
Do you have any biological children?
1 = yes
If yes, how many? _______
0 = no
Have you ever been a foster parent?
1 = yes
0 = no
Do you have any experience working with children/youth?
1 = yes
0 = no
Do you have any experience working with or being around gay/lesbian/bisexual/transgender/questioning youth?
1 = yes
0 = no
8 = don’t know
Do you have any experience caring for gay/lesbian/bisexual/transgender/questioning youth?
1 = yes
0 = no
8 = don’t know
Are you comfortable being around gay/lesbian/bisexual/transgender/questioning people?
1 = yes
0 = no
8 = don’t know
Are you willing to learn about how to best support gay/lesbian/bisexual/transgender/questioning youth?
1 = yes
0 = no
8 = don’t know
Emotional Permanency Survey
We are doing a study about youth in the child welfare system. We want to get the opinions and attitudes of caregivers who make permanent homes for these youth. Please answer yes or no when I ask the questions.
[Circle the response.]
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Is there anything else that you have experienced (or anticipate) with [insert youth name here] that shows that the two of you feel close?
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Supporting/Rejecting Attitudes Scale (MHI) Adult
NOTE: Hand the respondent the rating card and read the following statement aloud.
We are doing a study about youth in the child welfare system. We want to get the opinions and attitudes of caregivers who provide temporary and permanent homes to these youth. We want to know your beliefs and attitudes about youth sexuality and youth sexual orientation.
I am going to read you some statements. I would like you to rate how much you agree or disagree with each of the statements. Use one of the phrases on this card [point to card] to answer:
strongly disagree,
disagree,
somewhat disagree,
neither agree or disagree,
somewhat agree,
agree, or
strongly agree.
There are no right or wrong answers. We want this information so that we can better provide services to youth and their caregivers.
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Disagree |
Somewhat Disagree |
Neither Agree or Disagree |
Somewhat Agree |
Agree |
Strongly Agree |
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NOTE: this instrument is based on the Multidimensional Heterosexism Inventory (MHI) developed by Walls, 2005. See Walls, N. (2008) Toward a Multidimensional Understanding of Heterosexism: The Changing Nature of Prejudice, Journal of Homosexuality, Vol. 55, No. 1: 20-70.
Supportive/Rejecting Attitudes-Genderism and Transphobia Scale
NOTE: Hand the respondent the rating card and read the following statement aloud.
We are conducting a study about youth in the child welfare system. As part of this study, we want to capture the opinions and attitudes of caregivers who provide temporary and permanent homes to these youth. Specifically, we are interested in your beliefs and attitudes about youth sexuality and gender variant youth or those that identify as transgender (born one sex but identify with the opposite sex).
I am going to read some statements and I would like for you to rate how strongly you agree or disagree with each of the statements by looking at this card [POINT TO CARD] and selecting one of the following options:
strongly disagree,
disagree,
somewhat disagree,
neither agree or disagree,
somewhat agree,
agree, or
strongly agree.
There is no right or wrong answer. We want your opinion about youth sexuality and gender variant youth so that we can better provide services to youth and their caregivers.
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Strongly Disagree |
Disagree |
Somewhat Disagree |
Neither Agree or Disagree |
Somewhat Agree |
Agree |
Strongly Agree |
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NOTE: this instrument is based on a standardized scale developed by Hill and Willoughby, 2005. See Hill, D.B., and Willoughby, B.L.B. 2005. The Development and Validation of the Genderism and Transphobia Scale, Sex Roles, Vol. 53, No. 7/8: 531-544.
__________________________________________________________________________________________The collection of information described in this consent is voluntary. 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. The OMB control number for this collection is 0970-0408 and it expires XX/XX/XXXX.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Liz Quinn |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |