Attachment 2A-8: Parent-Legal Guardian Informed Consent and Questionnaire Telephone 10-15
CAPP Parent and Legal Guardian Informed Consent – Telephone
The U.S. Department of Health and Human Services has asked Westat, a research organization, to do a study on how child welfare services are helping families like yours. They want to know if the services you receive help children safely stay out of foster care or safely leave foster care sooner. One of the ways you can help us learn to better serve you and your children is by completing this telephone survey.
If you agree to participate, you will be mailed a $50.00 Visa gift card to thank you for your time and responses.
Your responses will not be provided to your social worker, cannot be used in court and will not affect your child welfare case.
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.
What is the study for?
The study will help us learn if the services you get from child welfare help your children safely stay out of foster care or safely leave foster care sooner.
How do I participate? How does the study work?
We are asking you to agree to let Westat gather information about you and your family. Westat will get this information through this questionnaire. The questionnaire asks questions about how you work with your social worker and the support and service you receive from your social worker. Other questions will be about other family members’ and friends’ involvement with your child’s case and how hopeful you feel about your child returning home.
The questionnaire will take about 36 minutes to answer. You can skip questions that you do not feel comfortable answering. There are no right or wrong answers. We just want you to answer the questions honestly.
What are the possible risks and discomforts?
This questionnaire has questions that may make you feel upset or uncomfortable. If that happens please speak to your social worker. You can also skip questions that 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 include information that specifically names you or your family in any reports. All responses will be compiled with responses from other families and will be used 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. We are mandated reporters, so if we are informed of any abuse or neglect we are required by law to report this information to child welfare. We are also required to report to authorities if we are concerned that you might harm yourself.
What are the benefits to participating in the study?
Your participation will help (insert CAPP agency name) find better ways to serve families and children.
Are there other ways to participate in the study?
There are no other ways to participate in the study other than completing this questionnaire.
Could I be injured by participating in the 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.
Does Westat have a conflict of interest with Department of Social Services (DSS)?
Westat has no financial or other relationships with (insert CAPP agency name) that will affect conducting this study, including interpreting and reporting the study results.
Will I get anything for taking part in the study?
We will mail you a $50.00 Visa gift card to thank you for participating in the survey.
I would like to participate in the study, but I have questions. Who can I contact?
I can answer questions for you. If you have any questions about the study after we complete the questionnaire, please call Westat at 1-855-538-6735. They are available from 9:00 a.m. to 3:00 p.m. PST and are happy to speak with you.
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. 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 previously mailed to you.
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. Your choice will not affect your case or the services that you and your family get. We hope that you will be part of the study so that we can learn ways to better serve families.
Participation Decision
Do you agree that you have received a copy of the Research Participant’s Bill of Rights, and will take part in the telephone survey?
Yes No
Mailing Address for Incentive
Please list the address for Westat to mail the $50.00 Visa gift card.
Name: _____________________________________________________________________
Address Line 1:________________________________________________________________
Address Line 2: _______________________________________________________________
City, State Zip: ________________________________________________________________
Phone (please include area code): (_____) ___________-__________
Date of IRB approval of this consent: TBD
Expiration date of IRB approval of this consent: TBD
OMB
NO: TBD
EXPIRATION
DATE: TBD
Burden
Statement: Public
reporting burden for this collection of information is estimated to
average .6 hours per respondent. These estimates include the time for
reviewing instructions, 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.
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:
Be told the nature and purpose of the study.
Be given an explanation of what will happen during the study and of how the research participant is expected to participate.
Be given an explanation of any risks or discomforts that may be experienced as a result of participating in the study.
Be given an explanation of any benefits that may be expected from participation in the study.
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.
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.
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.
Be told that you may refuse to answer any question.
Be given a copy of the signed and dated consent form.
Be free of pressure when considering whether to consent to, and participate in, the study.
Be informed, upon request, about the results of the study.
CAPP Parent and Legal Guardian Questionnaire
INTERVIEWER: Thank you for answering the questions on this questionnaire. Many of the questions will ask you about your child who is involved in Child Welfare Services, sometimes called “CPS”, and the social worker at (insert County and/or Office Name here) Child Welfare Services who has been working with you and your family.
If you have more than one child in Child Welfare Services, please answer these questions with the social worker of your oldest / youngest child in mind.
NOTE: Prior to engaging the respondent in the telephone interview, the interviewer will ask for their Survey ID printed on the survey packet envelope and survey itself. The Survey ID will indicate if the respondent will answer the questions with their oldest or youngest child in Child Welfare Services in mind.
What is the name of your oldest / youngest child in Child Welfare Services? ________________________
What is the name of their social worker? __________________________________________
Please think about these two individuals above whenever you are asked about “the social worker” or “your child.” Your responses will not be provided to your social worker, cannot be used in court, and will not affect your child welfare case.
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
INTERVIEWER: Please think about your experiences with the social worker you named at the beginning of the questionnaire, and your response to the following statements. For each statement, there are five response options. I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
1. In the last 3 months, this social worker has taken the time to listen to things I have to share about my family.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
2. In the last 3 months, this social worker has kept me informed about appointments, meetings and court dates.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
3. In the last 3 months, this social worker has asked about relatives and other people in my life who are helping me.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
4. In the last 3 months, this social worker has asked me about supports and services that my child needs.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
5. In the last 3 months, this social worker has asked me about supports and services that my family needs.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
6. In the last 3 months, this social worker has tried to learn about my family’s values, beliefs, culture and traditions.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
7. In the last 3 months, this social worker has respected my family’s values, beliefs, culture and traditions when making decisions about supports and services for us.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
8. In the last 3 months, this social worker has tried to understand the things that have had a major impact on our family.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
9. In the last 3 months, this social worker has been honest.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
10. In the last 3 months, this social worker has been respectful.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
11. In the last 3 months, this social worker has made an effort to understand the grief and pain my family is feeling as a result of my child being placed in foster care.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
Section B
INTERVIEWER: These questions ask you about the people in your life, such as family members and other people in your community or tribe who work closely with you and support you during your Child Welfare Services case. These are people other than your Child Welfare Services social worker or other child welfare staff. Your social worker may sometimes call this group of people your “circle of support.” Please think about the people who have played an important role in helping and supporting your family during your involvement with Child Welfare Services over the past 3 months.
12a. INTERVIEWER: I would like to make a list of who you consider to be in your circle of support. First, I will name a person that has been helping you. Please indicate Yes or No if that person has been in your circle of support over the past 3 months. You can say Not Applicable if the person is deceased; the relationship doesn’t exist (for example, you don’t have a brother or a sister); or if the person is not in your life.
Person Category |
12a. Is this person a part of your circle of support? |
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Your mother |
Yes |
No |
N/A |
Your father |
Yes |
No |
N/A |
Your sisters (s) |
Yes |
No |
N/A |
Your brother(s) |
Yes |
No |
N/A |
Your grandparent(s) |
Yes |
No |
N/A |
Your adult child(ren) |
Yes |
No |
N/A |
Your cousin(s) |
Yes |
No |
N/A |
Your stepmother |
Yes |
No |
N/A |
Your stepfather |
Yes |
No |
N/A |
Your aunt(s) |
Yes |
No |
N/A |
Your uncle(s) |
Yes |
No |
N/A |
Your friend(s) |
Yes |
No |
N/A |
Your neighbor(s)/co-worker(s) |
Yes |
No |
N/A |
Your child’s father/mother |
Yes |
No |
N/A |
The family of your child’s father/mother |
Yes |
No |
N/A |
Your child’s teacher |
Yes |
No |
N/A |
Your counselor(s) or therapist(s) |
Yes |
No |
N/A |
Spiritual leader/advisor, minister, pastor or priest |
Yes |
No |
N/A |
Elder(s), leader(s), member(s) of your community or tribe |
Yes |
No |
N/A |
12b. INTERVIEWER: I would now like to figure out which 3-5 persons in your circle of support have been the most helpful to your family during your involvement with Child Welfare Services over the past 3 months. I will name several options, and you can indicate up to 5 persons who have been most helpful. NOTE: Interviewer may skip options where the respondent indicated N/A in Question 12a.
Relationship Codes |
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INTERVIEWER: Thank you. I will now ask some questions about how you have worked with your circle of support. For each statement, there are five response options. I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
13. In the last 3 months, my circle of support and I have worked together to find solutions to the problems my family is facing.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
14. In the last 3 months, my circle of support has helped me do what I need to do to bring my child home and to close my family’s case.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
15. In the last 3 months, my circle of support and I have worked as a team to develop services and supports that respect my family’s way of life, our preferences, and our priorities.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
16. In the last 3 months, when I’m in meetings with Child Welfare Services about my child, my circle of support and I have had the opportunity to express our goals for my family.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
Section C
INTERVIEWER: These questions ask about how you feel about your family’s future in relation to your child coming home. Please think about the child involved with Child Welfare Services that you identified at the beginning of the questionnaire when you answer these questions. For each statement, there are five response options. I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
17. In the last 3 months, I have gotten the support I needed to help me with my feelings in this situation.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
18. In the last 3 months, my child has gotten the support he/she needed to deal with his/her feelings about this situation.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
19. I believe I can influence the decisions that are being made about my child’s future.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
20. I believe that my child will have family and other loving relationships to support him/her through his/her life.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
INTERVIEWER: The response options for this next question are Yes, Maybe, or No.
21. I believe that my child will be able to live safely with me without Child Welfare Services being involved.
a. Yes – CONTINUE TO QUESTION #22
b. Maybe – CONTINUE TO QUESTION #22
c. No – SKIP TO QUESTION #26
INTERVIEWER: The response options for these next questions go back to five. For each statement, I’ll ask, “Would you say very much so, for the most part, somewhat, only slightly, or not at all.”
22. I believe that friends and family will give me the help and support that I need to care for my child at home.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
23. I believe I can handle most of the difficulties I might face in caring for my child when he/she comes home.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
24. I believe I can count on myself to manage things well at home when my child comes home.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
25. I believe I can make plans for my family’s future and take steps to make those plans come true.
a. Very much so
b. For the most part
c. Somewhat
d. Only slightly
e. Not at all
Section D
Case Activities with Family and Friends
INTERVIEWER: You may have children involved in Child Welfare Services other than the child you named at the beginning of the questionnaire. Please answer these next questions about any of your children. Please answer Yes or No to the questions.
26. I have told my social worker about family or friends who may be able to help my child(ren) and me reunite and stay together as a family.
a. Yes – CONTINUE TO QUESTION #27
b. No – SKIP TO QUESTION #29
27. These family members or friends are helping my child(ren) and me reunite and stay together as a family.
a. Yes
b. No
28. The family or friends that I have identified have participated with me in one or more team meetings with my social worker.
a. Yes
b. No
29. Case Activities with Community Representatives
INTERVIEWER: Please answer these next questions thinking about case activities with Community or Tribal representatives. Community and Tribal representatives include:
Teachers
Counselors or therapists
Spiritual or Church leaders or advisors, such as ministers, pastors or priests
Other community leaders or elders
Other tribal representatives
Please answer Yes or No to the questions.
29a. I have told my social worker about Community or Tribal representatives who are important to my child(ren) or our family.
a. Yes – CONTINUE TO QUESTION #30
b. No – SKIP TO QUESTION #32
30. Community or Tribal representatives are helping my child(ren) and me reunite and stay together as a family.
a. Yes
b. No
31. Community or Tribal representatives have participated with me in one or more team meetings with my social worker.
a. Yes
b. No
Case Activities with You
INTERVIEWER: Please answer these next questions thinking about case activities with your social worker and you. Please answer Yes or No to the questions.
32. With my social worker, I have identified ways to change my behavior so my child(ren) can be safe in my care.
a. Yes
b. No
33. I have taken steps to change my behavior so my child(ren) can be safe in my care.
a. Yes
b. No
34. My social worker and I have talked about how I am changing my behavior so my child(ren) can be safe in my care.
a. Yes
b. No
35. I have completed one or more supervised visitations with one or more of my child(ren).
a. Yes
b. No
c. I have not been cleared for visitation with my child(ren).
36. I have completed one or more unsupervised visitations with one or more of my child(ren).
a. Yes
b. No
c. I have not been cleared for visitation with my child(ren).
37.
I have completed one or more overnight visitations with one or more
of my child(ren).
a. Yes
b. No
c. I have not been cleared for visitation with my child(ren).
Section E
INTERVIEWER: This is the final portion of the questionnaire. These last questions ask for some general information about you and your child. The response options are different for each question, so I will review the response options for each one as I ask the question.
38. How many children do you currently have involved with Child Welfare Services? _____
39. Thinking about the child named at the beginning of the survey, what is this child’s gender?
a. Male
b. Female
40. What is this child’s date of birth? __ MM / __ DD / ____ YYYY
41a. Is this child Hispanic, Latino, or Spanish?
a. Yes
b. No
41b. What is this child’s race? (Please chose one or more)
a. American Indian
b. Alaska Native
c. Asian
d. Black or African American
e. Native Hawaiian or Other Pacific Islander
f. White
g. Other, please specify: _______________________
42. What is your relationship to this child?
a. Biological mother or father
b. Adoptive mother or father
c. Relative guardian (please specify: ___________________)
d. Non-relative guardian (please specify: _________________________)
43. What is your gender?
a. Male
b. Female
44. What is your age? _____ years
45a. Are you Hispanic, Latino, or Spanish?
a. Yes
b. No
45b. What is your race? (Please chose one or more)
a. American Indian
b. Alaska Native
c. Asian
d. Black or African American
e. Native Hawaiian or Other Pacific Islander
f. White
g. Other, please specify: _______________________
You have reached the end of the questionnaire.
Thank you for participating.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | cyrstacer |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |