AI/AN FACES 2019 parent consent form

ATTACHMENT 16

AI/AN FACES 2019 PARENT CONSENT FORM

AI/AN FACES 2019 CONSENT FORM

We invite you and your child to take part in the American Indian and Alaska Native Head Start Family and Child Experiences Survey 2019, known as AI/AN FACES 2019. AI/AN FACES 2019 is the second round of the AI/AN FACES study, which in 2015 became the first national study to collect information about the characteristics and experiences of children and families served by Head Start programs in American Indian and Alaska Native communities. AI/AN FACES 2019 will help us learn more about children and families in AI/AN Head Start programs and the services Head Start provides. It will allow Head Start to better serve the needs of children and families in tribal Head Start programs. We are inviting you and your child to participate because your child attends a Head Start program included in the AI/AN FACES 2019 Study. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is paying for AI/AN FACES 2019. Mathematica, an independent firm, is conducting the study.

If you agree to take part…

We will ask you to fill out two surveys, one this fall and one in spring 2020. You can choose to fill out the survey online or by phone. We will ask you about your child, your family’s activities and routines (such as eating meals together), your feelings, and your health. The surveys will take about 30 minutes each. If you want to fill out the survey online but do not have internet access, you can fill it out online at your child’s Head Start center during the week the AI/AN FACES 2019 data collection team is visiting. During that week, computers will be available for you to use.

We will conduct an AI/AN FACES 2019 child assessment with your child this fall and in spring 2020 so we can find out how Head Start helps children learn and grow. During the child assessment, we will ask your child to do some fun activities with a trained member of our study team. For example, we will ask your child to look at pictures, copy drawings, and answer simple math questions. During this time we will also record your child’s height and weight. This will take about 60 minutes.

You will receive a gift card, and your child will receive a book. After you finish your survey this fall and again in spring 2020, we will send you a $30 gift card. After your child finishes the child assessment, we will give him or her a children’s book as a special thank you.

We will ask your child’s Head Start teacher 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. Your child’s teacher will fill out a brief survey with questions about your child’s behavior, skills, and any special concerns or disabilities. Your child’s classroom will be observed by a trained member of the study team once in spring 2020 so that we can learn more about how Head Start teachers work with the children in their classrooms.

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 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 AI/AN FACES 2019 child assessment. We will only report study results for parents, children, and programs as a group. All information collected as part of AI/AN FACES 2019 will be kept private 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 AI/AN 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 AI/AN FACES 2019, please call Sarah Forrestal, the survey director, toll free at 844-807-6007. You can find out more about AI/AN FACES 2019 on the study website at http://www.acf.hhs.gov/programs/opre/research/project/american-indian-and-alaska-native-head-start-family-and-child-experiences-survey-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 if you would like to take part. 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 AI/AN FACES 2019 study staff collect some information from my child’s Head Start teacher about my child’s behavior, skills, and any special concerns or disabilities. I also agree to take part in the study by filling out a survey. I will receive a $30 gift card after I fill out the survey in the fall, and again after I fill out the survey in the spring. My child will receive a children’s book each time he or she is assessed by the study team. I can 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 Tribal language ________________  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.