Attachment B

attachment B.2

Parent Letter and Consent Form

1100 1st Street, NE, 12th Floor

Washington, DC 20002-4221

Telephone (202) 484-9220

Fax (202) 863-1763

www.mathematica-mpr.com

FACES PILOT STUDY CONSENT FORM

We are inviting you and your child to take part in the Head Start Family and Child Experiences Survey (FACES) Pilot Study in which your child’s Head Start program is participating. The purpose of this study is to learn how to better assess the development of children in order for Head Start to better serve the needs of the children who attend the program. FACES is sponsored by the Administration for Children and Families of the U.S. Department of Health and Human Services and is being conducted by Mathematica Policy Research, an independent research company.

If you agree to participate…

We will ask you to take part in a survey. We will ask you a few questions about how your child is doing. The survey will take 10 minutes. We will give you a $15 gift card after the interview to thank you for your help. Once you complete the survey, we may contact you again to ask questions about your experience completing the survey. This phone call would take about 30 minutes, and we would give you a $20 gift card to thank you for your help.

We will do some activities with your child so we can find out how Head Start can better help children learn and grow. We will ask your child to take part in some fun activities with a trained assessor. These activities take about 60 minutes. For example, we will ask your child to look at pictures and answer some questions.

You can choose whether you and your child will be part of the study. Your participation and your child’s participation are completely voluntary. If you decide to be in the study, you can withdraw at any time without penalty. There are no known risks of participating in this study except for the possible discomfort of answering sensitive questions. You can choose not to answer any question that makes you uncomfortable. Your decision will not influence the Head Start services you and your child are receiving. No one from the Head Start program will see or hear your answers or be informed about how your child does on the activities. All of the study results will be reported for groups of parents and children, and no results will be reported for individuals. There is one exception—if we learn that a child has been abused or is endangered, we are required by law to report this information to the appropriate authorities, which could result in official action in accordance with state law.

If you have any questions about the FACES study, please call us toll free at 1-800-xxx-xxxx. A member of our staff would be happy to talk with you. If you have any questions about your rights as a research volunteer, please call Margo Campbell toll free at 1-800-757-4778.

We hope you will help us with this important project by agreeing to participate. Please sign the consent form included and return it to your child’s teacher right away. Thank you!

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0355. This information collection is voluntary. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Jerry West.

I have read this consent form and understand what I am being asked to do.

I agree to have my child participate in this study. I will be given a $15 gift card for participating in a survey. I understand that I may also be asked to answer some follow-up questions after I complete the survey, and I would be given a $20 gift card if I participate in that activity. I may withdraw this consent at any time without penalty.

1. Child’s Name

2. Parent/Guardian Signature Date

3. Parent/Guardian Name (Print)

4. Your Relationship to Child  Mother  Father  Grandmother  Other Guardian

5. Home Phone Cell/Other Phone

6. Email address _____________________________

7. Child’s Name (Print)

8. Child’s Gender  MALE  FEMALE

9. Child’s Birthday

Month Day Year

10. What language does your child use most often at home?

 English  Spanish  Other

11. Please interview me in:  English  Spanish  Other

12. Do you have access to a computer, laptop or other device that gives you access to the Internet?

 Yes  No

White Copy to Mathematica Yellow Copy to Center Liaison Pink Copy to Parent/Guardian