FACES 2019 parent consent form

ATTACHMENT 7

FACES 2019 PARENT CONSENT FORM

FACES 2019 CONSENT FORM

We invite you and your child to take part in the Head Start Family and Child Experiences Survey 2019 (FACES 2019). We are inviting you because your child is in a Head Start program that is taking part in this study. FACES 2019 aims to learn more about families in Head Start and the services Head Start provides. This study will help Head Start serve all children and their families. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is funding FACES 2019. Mathematica, an independent firm, is conducting the survey.

If you agree to take part…

We will ask you to complete a survey this fall and next spring via the web or over the phone. We will ask you about your child, your family’s activities and routines, your feelings, and your health. These surveys will take about 25 minutes. We will conduct them in your language.

We will do some activities with your child so we can find out how Head Start helps children learn and grow. This fall and next spring, we will ask your child to do some fun activities with a trained researcher. For example, we will ask your child to look at pictures, copy drawings, and answer questions. This will take about 60 minutes. During this time we will also record your child’s height and weight. We will do the activities in English or if your child speaks Spanish, we can do the activities in whichever language your child knows best.

We will offer a gift card for your help. You will have the option to do the survey by phone or on the web. If you do not have internet access, you can complete the survey at your child’s Head Start center during the week the FACES 2019 data collection team is present. After you complete the survey, as a thank you, we will send you a $30 gift card. After your child completes the activities, we will give him or her a children’s book as a special thank you.

We will ask your child’s Head Start teachers some questions about your child and will observe your child’s classroom. This will help us learn more about the progress your child is making in Head Start.

You can choose whether you and your child will be part of the study. Taking part is completely voluntary. Your choice to take part or not will not affect the Head Start services you and your child receive. If you choose to take part in the study but then decide you want to leave the study at any point, that is okay. We may also contact you in future years to learn more about your family’s experiences in and after Head Start.

We will protect your privacy. No one from Head Start will see or hear your answers to the questions in the parent survey or learn about how your child does on the FACES 2019 child assessment. We will only report study results for parents, children, and programs as a group. All information collected as part of FACES 2019 will be kept private to the extent permitted by law unless we learn that a child has been hurt or is in danger or you tell us that you plan to seriously hurt yourself or someone else – then by law, we must make a report to the appropriate legal authorities. In the future, survey responses from the study (with nothing identifying individuals, programs, or communities) may be securely shared with qualified individuals for additional learning purposes to better understand the strengths and needs of children and families in Head Start and the programs that serve them.

We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us protect your privacy. This means no one can force the study team to give out information that identifies you, even in court. However, we may need to share your information if it shows a serious threat to you or to others, including reporting to authorities when required by law. The U.S. Department of Health and Human Services (DHHS) may ask for data for an audit or evaluation. If they do, we will need to provide it. However, only DHHS staff involved in the review will see it.

If you have questions about FACES 2019, please call Sarah Forrestal, the survey director, toll free at XXX-XXX-XXXX. A staff member will be happy to talk with you. You can find out more about FACES 2019 on the FACES 2019 website. Visit http://www.acf.hhs.gov/programs/opre/hs/faces.

We hope you will take part in this study. Please sign the attached consent form and return it to your child’s teacher right away. Thank you! You may also provide consent online and complete your survey by visiting the following website: [URL].

I have read this consent form and understand what I am being asked to do.

I agree to have my child take part in this study. I also agree to have FACES 2019 researchers collect some information from my child’s Head Start teacher. I also agree to participate in the study by completing a survey. I will receive a $30 gift card after each time I complete a survey. My child will receive a children’s book each time he or she is assessed. I may withdraw this consent at any time without penalty.

1. Child’s name (print)

2. Parent/guardian signature 2a. Today’s date

3. Parent/guardian name (print)

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

5. Home phone ( )___________________

6. Cellular/other phone ( )___________________

6a. Does your cellular phone plan have unlimited minutes?*

 Yes  No

6b. May we send you text messages?*

 Yes  No

7. Address :

Address 1 Address 2

City State Zip

8. Email address

9. Do you have access to a smart phone, laptop, computer or other device that gives you access to the Internet?

 Yes  No

10. Child’s sex  Male  Female

11. Child’s birthday

Month Day Year

12. What language does your child use most often at home?

 English  Spanish  Other

13. What language would you like to use to complete your survey?  English  Spanish  Other

* In case you would like to complete your parent survey using your cell phone. Also, we may text you to remind you about the parent survey or child assessment.

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: This 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 the described collection is 0970-0151 and it expires 04/30/2022. The time required to complete this collection of information is estimated to average 10 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: Mathematica, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Lizabeth Malone.