Head Start Family Voices Pilot Study

ATTACHMENT A2

PARTICIPANT RECRUITMENT FORM

OMB No: Expiration Date: Head Start Family Voices Pilot Study Participant Recruitment Form
Program:			Interview Type: [pre-fill early head start or head start]
Address:			Phone:
City:		State:	Fax:

Instructions

1. Confirm all pre-filled contact information for your program. Indicate any special considerations in the box located on the top of page 2, including specific program requirements or requests.

2. Complete the proposed interview schedule on page 2. Based on the information shared with us by your program, we have indicated the number and characteristics of participants we would like to interview from your program. We will complete half of the interviews in person (Box A), and the other half by phone (Box B). Information on the number of parents to be interviewed from each program option (home-based or center-based) has been pre-filled. We have also indicated which interviews we would like to complete in Spanish. Please do not change any of the pre-filled information unless you have discussed it with us first.

3. Please consider the following in identifying staff and parent participants:

   • If your program provides both Early Head Start and Head Start services, we would like for you to only recruit staff and parents in [pre-fill early head start or head start].

   • Please distribute two copies of the consent form to staff and parents who agree to participate. Have them sign and return one copy. The other copy is theirs to keep.

   • Participating staff will include home visitors/educators, as well as family services staff (which may include family service workers, family services managers, and family services coordinators).

   • We would like to interview parents with different types of needs. Please recruit at least one parent in each of the following groups: [pre-fill based on screener] teen mothers, single-parent families, families who live in transitional housing or may be homeless, and parents who may have mental health problems. [include only if program offers early head start services]: We would also like to interview at least one parent who is enrolled in the program because she is pregnant.

   • We also want to interview parents who are challenging to engage in the program, and those who engage more readily.

4. Return the completed form, along with signed copies of staff and parent consent forms, to your Mathematica Coordinator no later than [date].

Mathematica Coordinator: Name: Address 1: Address 2: Phone: Fax: Email address:	On-Site Coordinator: Name: Position/Title: Address 1: Address 2: Phone: Fax: Email address:
Mathematica Field Interviewer: Name: Address 1: Address 2: Phone: Fax:	Interview Location: Address 1: Address 2: Phone:

Special Considerations

Interview Schedule
box a. interviews to be completed in-person from [pre-fill in-person interview window]
Participant Name	Participant Type	Language	Interview Date/Time	Interview Location
box b. interviews to be completed by phone [pre-fill phone interview window]
Participant Name	Participant Type	Language	Interview Date/Time	Telephone Number