12-Revised Provider Consent Form_Clean_June 2013

OMB Control Number: 0970-0355

Expiration Date: 1/31/2015

Measurement Development:

Quality of Family-Provider Relationships in Early Care and Education

Early Education/Care Provider Consent Form

Child Trends is doing a research study with individuals who provide care or education for young children. This is information that we ask you to use in deciding whether or not you want to take part in the study. You will be given a copy of this form to keep for yourself.

1. Goal:

The goal of our study is to develop questions about relationships between parents and those that care for/teach their young children. The questions will be used in national surveys, research studies, and program evaluations.

2. What will you need to do:

If you agree to be part of the study, you will be interviewed for about two hours. During the interview, we will ask you about relationships between parents and those that care for/teach their children. We will ask you to:

• Give us your thoughts about the meanings and wording of questions;

• Talk about how clear the questions are;

• Ask about any problems you think child care providers/teachers may have understanding the questions;

• Give ideas about how to word questions; and

• Talk about aspects of relationships between parents and those who care for/teach their children.

3. Risks and Benefits to Participants:

We will not be talking about any sensitive topics so the risks are minimal. However, there is some risk of loss of privacy of the things you tell us. You do not have to answer any questions you do not want to.

There are no costs related to the study other than the time needed to be part of the interview. We cannot be sure that everyone will benefit from being a part of the interview, but talking about this topic with others can be a learning opportunity. And, the results will help us improve questions about relationships that parents and teachers/caregivers have. To thank you for your time, you will receive $50 at the end of the interview.

4. Privacy:

Everything you tell us will remain as private as possible. We will combine what you and other tell us. This will help to reduce the chance that anyone can be identified when the study results are described. Only approved study staff will have access to the tape recordings and written notes. The tapes and notes will be kept in a locked file cabinet in a secured office. All computer files will be stored on a secure network.

There are limits to privacy. If someone on the study team feels that keeping information private would result in danger to you or another person, they will have to tell proper agencies to protect you or the other person. The types of information that would not remain private include any reports of the abuse or neglect of a child or any thoughts you may have to hurt yourself or anyone else.

Also, we would like your permission to record your interview so that we do not miss anything you say. We would also like your permission to use specific quotes from your interview in our reports. The quotes will not include any identifying information like names or birth dates. You can still participate in the interview even if you do not give your permission for us to record the interview or for us to use quotes.

5. Voluntary Participation:

Your participation in this study is voluntary. That means that you are free to not participate in the interview. Nothing bad will happen because you decide not to be in the study and you are not giving up any rights. If you learned about our study through a program you work in, your position in that program will not be affected. Also, once we begin, you may end the interview at any time.

6. Questions:

Please feel free to ask questions now or later. If you have any questions about the study, you may call Dr. Lina Guzman, at Child Trends at 202-553-2900 or 1-888-418-4585 between 9:00 a.m. and 5:00 p.m. EST. She will be happy to answer your questions.

If you do not wish to talk to her or you have concerns or complaints, you may contact the Institutional Review Board (IRB), a group that reviewed this study for your protection.

You may contact Kerry Levin, Chair of Westat’s IRB at KerryLevin@westat.com, or Sharon Zack, Westat’s IRB Administrator at SharonZack@westat.com or at 301-610-8828 and you can write them at: 1600 Research Blvd., Rockville, MD 20850.

Agreement: The researcher and I have read this information together and I have discussed it with him/her. I have read the study described above and have been given a copy of it. I am 18 years of age or older and I agree to take part in the study.

_______________________________ _________________________

Signature Date

I have also read that if someone on the study team feels that keeping information private would result in danger to me or another person, they will have to tell proper agencies to protect me or the other person.

_______________________________ _________________________

Signature Date

We would like to tape record the interview so that we can make sure that we don’t miss anything you say. We will also be taking notes. Please try not to use any identifying information (such as a full name) once we start recording.

Please know that you can still take part in the study even if you do not wish to be recorded.

Do we have your permission to tape record and transcribe the interview? YES NO

We also would like to use specific quotes from your interview in describing some of our results. However, all identifying information such as names or birthdates would be removed. Your identity will remain private. Please know that you can still participate in the study even if you do not want quotes from your interview used. You will have a chance to change your mind at the end of the interview as well.

Do we have your permission to use specific quotes from your interview in summaries, reports, and presentations of our study findings? YES NO

_____________________________ _________________________

Signature Date

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