Attachment 21 - Video Consent Father

Agreement to be Video-recorded for the

Building Bridges and Bonds (B3) Study

Congratulations on being part of the Just Beginning program! When you sign this form, you agree you can be video-recorded for research purposes. Your decision is voluntary. We hope you will agree to participate.

What does it mean to participate?

The B3 study team might like to record you during some of your play sessions with your child. No more than a total of 6 videos will be recorded.

You do not need to change anything you do in the session with the child. The study team member doing the recording will stay out of your way.

Video-recording is your choice

Recording you during sessions is your choice. It does not affect whether you can keep participating in B3 or program services. You may change your mind and decide not to be videotaped in the future.

How will my information be protected?

As with your other information from the study, we will follow strict rules to protect your video-recordings. Video recordings will be kept in password-protected computer files and will be marked with a special code number, not your name. None of our research reports will describe you in a way that would allow you to be identified.

The study has a Certificate of Confidentiality from the U.S. government. This certificate says that we do not have to identify research subjects, even under a court order or subpoena. We will keep your information private to the extent permitted by law. For example, if there is concern that you or someone else may be harmed, we will have to tell the appropriate agencies to protect you and that other person. The government may see your information if it audits the study, but it would keep your child’s information private.

What are the risks and benefits?

The recordings might help improve services for other fathers and their families. There is a small risk of the information being seen outside of the study team in the unlikely event of a data breach, such as a breach in computer security.

What if I have questions?

You can reach MDRC and Building Bridges and Bonds (B3) at B3@mdrc.org or 1-855-907-6703.

Participant’s statement:

“I agree to have my image and voice recorded for the B3 project. Videos will show me and my child playing together. I understand that only my image and voice as they appear during the session will be on the video, not my name. Videos will not be sold. They will not be used for commercial purposes.

The video-recording procedures, risks, and benefits have been explained to me. I know I am free to ask any questions. I understand it is my choice. I understand my information will be kept private, to the extent permitted by law, unless there is a concern that myself or someone else may be harmed.”

 By checking this box, I give permission to include the video-recording of me in a presentation about the B3 study that would be available to the public, for example at a research conference or on a web site about the study.

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Your Name (Print) Your Signature Date

This evaluation is being conducted on behalf of the Administration for Children and Families (ACF). 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 number for this information collection is 0970-0485 and the expiration date is 9/30/2019.