Permanency Innovations Initiative - AZ, CAPP, IL

A1. CAPP Frequently Asked Questions and consent Letter to parents and guardians with bill of rights

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

A1. CAPP Frequently Asked Questions and consent Letter to parents and guardians with bill of rights

This Document will be on Fresno County DSS Letterhead.

Dear Prospective Participant,

We want you to take part in a study with the Fresno County Department of Social Services (DSS). The U.S. Department of Health and Human Services hired Westat to do the study. Westat has no connection to Fresno County DSS except the study. Before you decide if you want to be in this study, we want you to understand why it is being done and what it will involve. The study is described below.

What is the study for?

This study will to find out if the service program in Fresno County helps children stay out of foster care or leave foster care sooner. We need your help in finding out which services work better.

What do you want me to do now?

We would like you to let Fresno County share your contact information with Westat. If you do not want Fresno County to give your contact information to Westat, please call the number below by (insert date). If you do not call the number below by (insert date), Fresno County DSS will give your contact information to Westat. Then, a Westat researcher will call you to tell you more about the study. Your choice will not make a difference in the services that you and your family get.

What will I have to do if I agree to be in the study?

If you want to be in the study, a Westat researcher will call you to tell you more about the study. If you agree to be in the study, the researcher will either ask you questions over the phone at that time or set up another time to talk to you. During this phone call, the researcher will ask you questions about yourself and your family. These questions will be about how well you work with your caseworker and the support and service you get from your caseworker. Other questions will be about how other family members and friends are involved with your child’s case and how hopeful you feel about getting your child back. The questions will take about 20 minutes.

The study will also involve reviewing your answers to the questions with information from your DSS records. These records have details about you and your family, services you received from DSS, and your family’s case progress. We will use this information only for the study.

What are the possible risks and discomforts?

We don’t think taking part in the study has much risk. If some of the questions make you feel upset or sad, you can talk with your caseworker. You can also skip questions you do not want to answer.

Will everything I tell you during the study be kept private?

We will keep your information private to the extent permitted by law. We will not use any information that can point to you or your family in any reports.

To help us protect your information, we received a Certificate of Confidentiality from the U. S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding under a court order or subpoena. But, we will in all cases take necessary action, including reporting to authorities, to prevent harm to yourself or others. This includes reporting suspected child abuse or neglect.

Will I get anything for taking part in the study?

We will mail you a $25.00 Wal-Mart gift card at your home address for participating in the survey.

Your participation will also help Fresno County DSS find better ways to serve families and children.

Do I have to take part in the study?

You do not have to be in the study. You can stop being in the study at any time. You can also choose to be in the study at a later time. Your decision will not change the services that you and your family already get.

What if I do not want Fresno County DSS to share my information?

If you do not want Fresno County DSS to give your contact information to Westat, please call __________ at ___-___-____ by (DATE TBD Pending OMB and IRB CLEARANCE).

What if I have questions about the study?

If you have questions about the study, contact Jennifer Dewey of James Bell Associates, Inc. at 1-800-546-3230 (General) or 703-246-2637 (Direct). If you have questions about your rights as a participant in the study, please contact the Committee for the Protection of Human Subjects at (916) 326-3660. You can learn more about your rights as part of the study from the attached Research Participant’s Bill of Rights.

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

Participant’s Bill of Rights for Non-Medical Research

You have been asked to participate in a research study. Any participant in a research study has
the right to:

1. Be told the nature and purpose of the study.

2. Be given an explanation of what will happen during the study and of how the research participant is expected to participate.

3. Be given an explanation of any risks or discomforts that may be experienced as a result of participating in the study.

4. Be given an explanation of any benefits that may be expected from participation in the study.

5. Be told of other appropriate choices that may be better or worse than being in the study, and be told of the risks and benefits of those other choices.

6. Have the opportunity to ask questions about the study or about your participation in it, both before agreeing to participate in the study and during the course of the study.

7. Be told that you may withdraw your consent and participation in the study at any time, and that your withdrawal will not affect your services.

8. Be told that you may refuse to answer any question.

9. Be given a copy of the signed and dated consent form.

10. Be free of pressure when considering whether to consent to, and participate in, the study.

11. Be informed, upon request, about the results of the study.

Declaración de Derechos de Participantes en estudios Nomedicos

(Spanish translation of Participant’s Bill of Rights for Non-Medical Research)

Se le ha pedido que participe en un estudio de investigación. Cualquier participante en un estudio de investigación tiene el derecho a:

1. Que se le diga la naturaleza y el propósito del estudio.

2. Que se le dé una explicación de lo que ocurrirá durante el estudio y de que manera se espera que participe el participante en una investigación.

3. Que se le dé una explicación de todos los riesgos o molestias que pueden ocurrir como resultado de la participación en el estudio.

4. Que se le dé una explicación de todos los beneficios que se pueden recibir de la participación en el estudio.

5. Que se le diga de otras alternativas apropiadas que pudieran ser mejores o peores que la participación en el estudio, y que se le diga de los riesgos y beneficios de esas otras alternativas.

6. Que tenga la oportunidad de hacer preguntas acerca del estudio o acerca de su participación en el estudio, antes de participar en el estudio y durante la duración del estudio.

7. Que se le diga que puede retirar su consentimiento y participación en el estudio en cualquier momento, y que su retiro no le afectará sus servicios.

8. Que se le diga que puede rehusarse a contestar cualquier pregunta.

9. Que se le dé una copia firmada y fechada de la forma de consentimiento.

10. Estar libre de presiones al momento de decidir si da su consentimiento para participar en el estudio.

11. Obtener información, en cuanto usted lo pida, acerca de los resultados del estudio.

(Traducido por J. Ruiz)

A2. CAPP Parent Study Contact Information Form

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

A2. CAPP Parent Study Contact Information Form

Parent Name		Relationship to Child

__________________________________

Caseworker name

Parent Contact Information

Phone:			Alternate Phone:
Address:
Apt/Room/Bldg:
City:			State:	Zip Code:

FOR OFFICE USE
Child Name:			Evaluation ID:
Approval to provide contact information: Yes No (Place in case file.)
Date task completed:		/ /

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

A3. CAPP Parent-Guardian Interview with Consent Script

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

A3. CAPP Parent-Guardian Interview with Consent Script

Verbal Consent Script:

Hello, my name is ______. I am with Westat. I am calling to follow up on a letter that Fresno County DSS sent to you about a study you can take part in. Can you talk with me about the study now?

If yes, say: Okay, before I go on, I need to let you know that I am taping this phone call so I can record if you want to take part or not.

If no, ask: Is there another time that I could call you back about the study?

If not interested in participating, say: Okay, that is no problem at all. Thank you for your time.

Introduction and PURPOSE OF STUDY

The U. S. Department of Health and Human Services has hired Westat, a research company, to study the services Fresno County Department of Social Services (DSS) gives to families. The study will help us learn if the services you get help children stay out of foster care or leave foster care sooner. We want your help in finding out if these services work. You do not have to be in the study. You can stop being in the study at any time. Your choice will not affect your case or the services that you and your family get.

Procedures

Fresno County looked into your family’s case and decided your family needs to get services. As a part of these services, a caseworker meets with you, makes home visits, works with other child welfare workers to give you services, and checks on how your family is doing. While you are getting these services, Westat wants to study how these services help families. To do this, we need to get information about you and your family.

We are asking you to agree to let Westat get information about you and your family. Westat will get this information during a one-time phone interview. The interview will ask questions about how you work with your caseworker and the support and service you receive from your caseworker. Other questions will be about other family member and friend involvement with your child’s case and how hopeful you feel about getting your child back.

You can ask the researcher questions at any time. You can skip questions that you do not want to answer. The questions will take about 20 minutes to answer. There are no right and wrong answers. We just want you to answer the questions honestly.

During the study, Westat researchers will review your answers to the questions and review information from your DSS records. This information has details about you and your family, services you received from DSS, and your family’s case progress. We are asking you to agree to let us study your answers together with the information we get from the DSS records. We will use this information only for the study.

RISKS TO PARTICIPANT

We don’t think being in the study has much risk. If any of the questions make you feel upset or sad, you can talk with your caseworker. You can also skip questions that you do not want to answer.

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.

ENSURING PARTICIPANT and data Privacy

We will keep your information private to the extent permitted by law. We will not include information that points to you or your family in any reports. We will use your information for research only.

To help us keep your information private, we received a Certificate of Confidentiality from the U.S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding or under a court order or subpoena. But, we will in all cases take necessary 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 researchers are collecting the data right, another Westat researcher may ask to listen in during the phone interview. We will ask you ahead of time so you can decide if the other researcher can listen in or not.

INCENTIVE FOR PARTICIPATING IN THE STUDY

You will be mailed a $25.00 Wal-Mart gift card at your home address for participating in the survey.

BENEFITS FOR PARTICIPATING IN THE STUDY

Your participation will help Fresno County DSS find better ways to serve families and children.

DIFFERENT WAYS TO PARTICIPATE

There are no other ways to participate in the study other than completing the phone survey.

CONFLICT OF INTEREST

Westat has no financial or other relationships with Fresno County DSS that will affect conducting this study, including interpreting and reporting the study results.

CONTACTS FOR QUESTIONS ABOUT THE STUDY

If you have any questions about the study, please call Jennifer Dewey at (800) 546-3230 (General Number), (703) 247-2637 (Direct Line), or dewey@jbassoc.com. If you have any questions about your rights as person taking part in the study, please contact the Committee for the Protection of Human Subjects at (916) 326-3660. This information is in the letter that DSS sent to you about the study. You can also learn more about your rights as a part of the study from the Research Participant’s Bill of Rights document that was sent to you by mail along with the study letter.

Voluntary participation

You can decide if you want to take part in the study. You can stop being in the study at any time. Taking part in the study or not will not affect your case or the services that you and your family get.

Participation decision

Do you have any questions about anything I read to you? Do you understand everything that I have read to you?

Do you agree that you have received a copy of the Research Participant’s Bill of Rights and agree to take part in the phone interview?

 Yes

If yes, ask: Do you agree to let Westat study your interview answers with the information we get from the DSS records?

 Yes  No

 No

If no, say: Okay, that is no problem. Thank you for letting me to tell you about the study.

OFFICE USE ONLY:

Child Evaluation ID______________________

___________________________________________________________________________

Study representative’s signature Date

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

Introduction

INTERVIEWER: As I said, the questions I’ll be asking you are about your family’s experiences with the Fresno County Department of Social Services—Child Welfare Services and the way they are working with your family with regard to [child’s name]. I’ll ask some questions about your experience with the social worker who is assigned to your family, and I’ll ask some questions about the supports and services you’re receiving from him or her. I’ll also ask you some questions about friends and family members who may be helping you through this and some questions about how you feel about your family’s future. Again, the questions will take about 20 minutes total.

Remember, you can ask me questions at any time if you don’t understand something and you can skip questions that you do not want to answer. There are no right and wrong answers. Please think carefully about each question and answer them to the best of your ability.

SECTION A: Respondent’s Relationship with CPS Caseworker

INTERVIEWER: I’d like to begin by asking you about your experiences with [social worker’s name], the social worker at Child Welfare Services — sometimes called “CPS”— who is working with your family regarding [child’s name]. I’m going to read some statements to you. As I do, please think about how things have been over the last 3 months in particular and then tell me how much you agree or disagree with each statement. For each statement there are five responses options: I’ll ask, “Would you say you strongly agree, mostly agree, mostly disagree, strongly disagree, or are you not sure?” Okay? Let’s begin.

1. My social worker takes time to ask about and listen to things I have to share about my family.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

2. My social worker keeps me informed about important things I need to take care of, such as meetings and court dates.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

3. My social worker asks about my relatives and other people in my life who might be helpful to my family right now.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

4. My social worker asks me about supports and services that I think my child and family need.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

5. My social worker makes an effort to learn about my family’s cultural values and traditions.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

6. My social worker respects my family’s cultural values and traditions when making decisions about supports and services for us.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

7. My social worker makes an effort to understand the things that have had a major impact on our family.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

8. My social worker is honest and respectful.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

9. My social worker makes an effort to understand the grief and pain my family is feeling as a result of my child being placed in foster care.

   1. Strongly agree

   2. Somewhat agree

   3. Mostly disagree

   4. Strongly disagree

   5. Not sure

SECTION B: Respondent’s Connectedness to “Circle of Support”

INTERVIEWER: Now I’d like to ask you about the people in your life, such as family members and other people in your community or tribe who have been working closely with you and supporting you during your Child Welfare Services case regarding [child’s name]. These would be people other than your CPS social worker or other child welfare staff. Your social worker may sometimes call this group of people your “circle of support.” I’d like to ask a few questions about who is in your circle of support and how they’re helping you with your case.

10. INTERVIEWER: First I’d like your help to make a list of who you consider to be in your own circle of support. I’ll ask you to name each person in your circle and I’ll ask you to tell me, on a scale of 1 to 5, how helpful you feel they’ve been to your family during your current involvement with Child Welfare Services. On this scale of 1 to 5, 5 is the most helpful they can be and 1 is the least. Is that clear? Let’s begin.

10a. Please name a person in your circle of support. [Interviewer prompt: Again, this is someone who is playing an important role in helping and supporting your family during your involvement with Child Welfare Services right now.]	10b. On a scale of 1 to 5, how helpful has this person been?
Specify:
Specify:
Specify:
Specify:
Specify:
Specify:

[NOTE: Once respondent has run out of circle of support members, Interviewer would move on to this prompted list.]

11. INTERVIEWER: To make sure we’ve identified everyone in your circle of support, I’m going to read a short list of people to see if any of these people might also be in your circle. As I read each person, please stop me and say yes if they’re involved in your circle of support.

Person Category	11a. Involved in circle of support?	If yes, ask 	11b. How helpful?
	Yes
Your mother
Your father
Your sister(s)
Your brother(s)
Your grandparent(s)
Your cousin(s)
Your stepmother
Your stepfather
Your aunt(s)
Your uncle(s)
Your friend(s)
Your child’s father/mother
The family of your child’s father/mother
Your child’s teacher(s)
Your counselor(s) or therapist(s)
Spiritual leader/advisor, minister, pastor, or priest
Elder(s), leader(s), member(s) of your community or tribe

[Interviewer prompts one last time: Is there anyone else you can think of in your circle of support?]

SECTION C: Circle of Support’s Involvement in Case Planning and Problem-Solving

INTERVIEWER: Now I’d like to ask you some questions about how you and your circle of support work together on your Child Welfare Services case regarding [child’s name]. As before, I’ll read a series of statements and for each one, please tell me how much you agree or disagree with that statement. Again for each statement there are five response options: strongly agree, mostly agree, mostly disagree, strongly disagree, or I’m not sure.

12. My circle of support and I are working together to find solutions to the problems my family is currently facing.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

13. My circle of support is helping me do what I need to do to bring [child’s name] home and to close my family’s case.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

14. My circle of support and I are working as a team to develop services and supports that are respectful of my family’s way of life, our preferences, and our priorities.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

15. When I’m in meetings with Child Welfare Services about [child’s name], my circle of support and I have the opportunity to express our goals for my family.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

SECTION D: Respondent’s Sense of Hopefulness & Locus of Control

INTERVIEWER: Now I’d like to ask you some questions about how you are feeling about your family’s future in relation to [child’s name] coming home. Again, I’ll read a series of statements and for each one, please tell me how much you agree or disagree with that statement. Again there are five options: strongly agree, mostly agree, mostly disagree, strongly disagree, or I’m not sure.

16. I’m getting the support I need for the stress I have felt in this situation.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. [Child’s name] is getting the support he/she needs to deal with his/her feelings about this situation.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I believe that [child’s name] will be able to live safely at home without Child Welfare Services being involved.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I believe that [child’s name] will have family and other loving relationships to support him/her through his/her life.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I believe that friends and family will give me the help and support that I need to care for [child’s name] at home.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I believe I can handle most of the difficulties I might face in caring for [child’s name] when he/she comes home.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I feel I can count on myself to manage things well at home when [child’s name] comes home.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I feel I can influence the decisions that are being made about [child’s name]’s future.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure

16. I feel I can make plans for my family’s future and take steps to make those plans come true.

1. Strongly agree

2. Somewhat agree

3. Mostly disagree

4. Strongly disagree

5. Not sure