Parent consent form

APPENDIX 27

PARENT AND CHILD CONSENT FORM

PARENT AND CHILD CONSENT FORM

We invite you and your child to take part in the Migrant and Seasonal Head Start Study (MSHS Study). We are inviting you because your child is in a MSHS program that is in this study. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is paying for this study. Abt Associates, The Catholic University of America and Westat are doing the study. We want to learn more about the families and children being served by MSHS. We also want to learn about your experiences with MSHS! If you agree to be a part of the study…

We will do some activities with your child to find out how MSHS programs help children learn and grow. If your child is a toddler or preschooler, we will ask your child to look at pictures, copy drawings, write, listen to a story, and answer a few questions. These activities will be used to measure his/her language and literacy skills. We can do these activities in about 30 – 40 minutes in English and Spanish, depending on the languages your child knows. Your child can take a break and go back to class at any time.

We will ask you to talk to us for about 1 hour in the language you are most comfortable with to help us learn about your child, your family, your feelings and the MSHS program. We will ask about your family’s health, the work your family does, and how you use child care. We will also ask you some personal questions about your feelings.

We will ask your child’s teacher questions about your child and will observe the classroom to help us learn what your child knows and the services that MSHS offers.

We will thank you and your child for your time. We will give you $30 cash. We will give your child a small gift that is worth about $2.

You can choose whether you and your child will be part of the study. Your participation is voluntary. The risks to participating in this study are very small. You can skip any questions. If you or your child decides to stop at any time, it is okay. We will not ask about your legal status in the U.S. Whether you or your child takes part in the study will not affect how your MSHS program treats you or your child or any benefits you receive. There will be no direct benefit to you for your participation in this study.

To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. We can use this Certificate to legally refuse to disclose information that may identify you in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings, for example, if there is a court subpoena. We will use the Certificate to resist any demands for information that would identify you, However, the Certificate of Confidentiality will not be used to prevent disclosure to state or local authorities of child abuse and neglect, or harm to self or others.

All collected study information is kept private. No one from your MSHS program will see or hear your or your child’s answers. We will report on the information from parents and children only as a group. We will give this information to other researchers who will use it to answer other research questions. These researchers may use the MSHS center zip code to link center information to information about the community. We will not identify you or your child to the researchers or in any report or materials from this study. We will make sure that all study team members use the information only for research. They will carefully follow the rules to keep your information secure and private. We will give the information to ACF without your name or other information that can be used to identify you.

If you have questions about the MSHS Study, please call us toll-free at 1-888-xxx-xxxx. A study member who speaks Spanish and English will be happy to talk with you. If you have questions or concerns about your rights in this study, please call the Abt Institutional Review Board toll-free at 1-877-520-6835.

Consent to Participate

I have read this consent form or have had it read to me. I agree to participate in an interview.

I agree to allow my child to complete the activities listed above. I agree to allow study staff to communicate with my child’s teacher to obtain additional information about my child.

I will receive $30 cash (per family). My child will receive a small gift worth $2 for participating. I know that my participation is voluntary. I and my child may stop at any time, without penalty. I have been told that Abt Associates and its partners will carefully protect my information, to the extent provided by law. I have been told they will not ask about my legal status in the U.S.

1. Child’s name (print)
   
   

2. Parent/guardian signature
   Today’s date
   
   

3. Parent/guardian name (print) __________________________________

4. Your relationship to child  Mother  Father  Grandmother  Other guardian

5. Home phone (______)___________________

6. Home address: ____________________________________________________

7. Cellular/other phone (______)___________________

May we call you to remind you about the parent survey or child assessment?

• Yes  No

8. Email address

9. Child’s gender  Male  Female

10. Child’s birthday

Month Day Year

11. What language(s) does your child use most often? Select only one.

 My child has not started talking yet.

 Only Spanish

 Only other language

 Only English

 Mostly Spanish, sometimes other language

 Mostly Spanish, sometimes English

 Mostly Spanish, sometimes other language and English

 Mostly other language, sometimes Spanish

 Mostly other language, sometimes English

 Mostly other language, sometimes Spanish and English

 Mostly English, sometimes Spanish

 Mostly English, sometimes other language

 Mostly English, sometimes Spanish and other language

 Spanish and English about equally

 Spanish and other language about equally

 Other language and English about equally

 Spanish, English, and other language about equally

 Other: Please describe: ______________________________________________

12. What language would you like to use to complete your survey?

 English  Spanish  Other ____________________________

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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. The OMB control number for this collection is 0970-0151 and it expires XX/XX/XXXX.

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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. The OMB control number for this collection is xxxx-xxxx and it expires XX/XX/XXXX. The time required to complete this collection of information is estimated to average 15 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Abt Associates, 55 Wheeler Street, Cambridge MA 02138 Attention: Linda Caswell