AIAN FACES 2019 special parent consent form for fall 2021 and spring 2022 data collection

Attachment 35

AIAN FACES 2019 Fall 2021 Special Parent Consent Form
for Fall 2021 and Spring 2022 Data Collection

This page has been left blank for double-sided copying.

AIAN FACES 2019 Special Parent Consent Form
for Spring 2022 Data Collection: Telephone Mode

AIAN FACES SPECIAL PARENT CONSENT FORM FOR SPRING 2022 DATA COLLECTION: VERBAL CONSENT

INSTRUCTION: USE [FILE] TO FILTER FOR HEAD START PROGRAM/CENTER, CHILD NAME, AND DOB.

RESPONDENT CALLS IN

1. Hello, my name is [INTERVIEWER_NAME]. Thank you for calling in to consent to participate in AIAN FACES. We are conducting this study to learn more about families in Region XI AIAN Head Start programs and the services Head Start provides. May I ask your name?

2. So I can check with my records, where does your child attend Head Start?

INSTRUCTION: USE PROGRAM AND CENTER NAME AND NICKNAME FIELDS AS WELL AS CITY AND STATE TO SEARCH AS NEEDED. IF CHILD IS NO LONGER ENROLLED IN/ATTENDING THE LISTED HEAD START PROGRAM, SAY:

Right now we are only looking at children attending Head Start. Thank you for your time today, but we will not be able to include you in the study at this time.

3. May I have the spelling of your child’s name?

4. What is your child’s birth date?

INSTRUCTION: IF NO FULL MATCH MADE, FLAG THIS CASE TO REVIEW WITH A SUPERVISOR AND SAY:

I’m sorry. I need to check my records before I can interview you. Is this the best time to reach you in the future? Is the phone number you are calling from the best one to use to call you back?

INSTRUCTION: IF A MATCH FOR ALL THREE ARE FOUND, LOGIN TO CONSENT FORM AND SAY:

Great, thank you. In case we get disconnected, is the phone number you are calling from the best one to use to call you back?

INTERVIEWER DIALS OUT

1. Hello, my name is [INTERVIEWER_NAME] at Mathematica. I am calling about a study we are conducting to learn more about families in Region XI AIAN Head Start programs and the services Head Start provides. May I please speak with [RESPONDENT_NAME]?

IF ABLE TO SPEAK WITH R: We would like to interview you about your child’s experiences in Head Start. Before beginning the interview, I’d like to provide information about the study and ask for your consent to participate. This will take about 10 minutes. Is now a good time?

IF GOOD TIME, GO TO QUESTION 2.

IF NOT A GOOD TIME: When would be a good time to call back?

PROBE: Hearing about your and your child’s experiences in Head Start is very important to the success of this study. If you would prefer to complete the consent form on paper or online instead, you should have received information via mail and/or email. Please let me know if you would like us to resend this information.

IF NOT ABLE TO SPEAK WITH R: When would be a good time to call back?

2. So I can confirm I’m speaking with the correct person, where does your child attend Head Start?

3. May I have the spelling of your child’s name?

4. What is your child’s birth date?

INSTRUCTION: IF NO FULL MATCH MADE, FLAG THIS CASE TO REVIEW WITH A SUPERVISOR AND SAY:

I’m sorry. I need to check my records before I can interview you. Is this the best time to reach you in the future? Is this phone number the best one to use to call you back?

INSTRUCTION: IF A MATCH FOR ALL THREE ARE FOUND, LOGIN TO CONSENT FORM AND SAY:

Great, thank you. In case we get disconnected, is this phone number the best one to use to call you back?

Verbal consent form for verified respondents

VERIFIED CASES ONLY – WEB FORM

First Intro.

We invite you and your child to take part in the American Indian and Alaska Native Head Start Family and Child Experiences Survey, known as AIAN FACES, spring 2022 data collection. AIAN FACES describes children and families participating in Head Start and their Region XI AIAN Head Start programs. Head Start will use the information gained from AIAN FACES to understand the unique needs of families two years after the COVID-19 pandemic began. We are inviting you and your child to participate because your child attends a Head Start program included in the AIAN FACES study. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is paying for AIAN FACES. Mathematica, an independent firm, is doing the study. Mathematica has worked with directors of Head Start programs in AIAN communities, the OHS leadership and other federal staff, and child development researchers to make sure the study meets the unique needs of AIAN Head Start programs.

If you agree to take part…

We will ask you to complete a survey soon via the web or over the phone. We will ask you about your child, your family’s activities and routines (such as eating meals together), your feelings, and your well-being during the COVID-19 pandemic. The survey will take about 40 minutes.

We will ask your child’s Head Start teacher some questions about your child in a teacher-child report. It will have questions about your child’s behavior, skills, and any special concerns or disabilities. This will help us learn more about how your child is doing in Head Start.

We will offer a gift card for your help. You will have the option to do the survey by phone or on the web soon. After you finish the survey, as a thank you, we will send you a $30 gift card.

You can choose whether you and your child will be part of the study. Taking part is completely voluntary. There are no risks or direct benefits from taking part in the study. 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.

wEB

Second Intro.

 

We will protect your privacy. No one outside of the Mathematica study team will be able to connect you to the answers you provide to the survey questions. Some questions might ask you to answer questions in your own words. We may use statements or parts of statements you make in connection with the study; however, we will not identify you as the source of the statement; we also will not identify your program or community. We never identify you or any other individual parent, child, or staff member in any report; reports contain only general study results. All information collected as part of AIAN FACES 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) will be securely shared only with qualified individuals who are studying Head Start children, their families, and programs.

We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us protect your privacy. This strictly limits when the study team can 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 AIAN FACES, please call the study staff including Sara Skidmore, the survey director, toll free at 833-961-2894. You can find out more about AIAN FACES on the study website at https://www.acf.hhs.gov/opre/project/american-indian-and-alaska-native-head-start-family-and-child-experiences-survey-ai-0.

We hope you will take part in this study. Thank you!

At this time, I will read two statements for you to confirm that you provide consent to participate.

wEB

CO0. I have had this consent form read to me and understand what I am being asked to do.

 Yes 1

 No 0 END

HARD CHECK: IF CO0=NO RESPONSE; You must answer this question to continue to provide consent.

If CO0a=0, status as Incomplete in SMS

CO0a. I agree to have AIAN FACES 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 completing a survey this spring. Some questions might ask me to answer questions in my own words. The study may use statement(s) or parts of statements I make in connection with the study; however, I will not be identified as the source of the statement; the study also will not identify my program or community. I will receive a $30 gift card after I fill out the survey this spring. If I choose to take part in the study but then decide I want to leave the study at any point, that is okay.

 Yes 1

 No 0 END

HARD CHECK: IF CO0a=NO RESPONSE; You must answer this question to continue to provide consent.

If CO0a= 0, status as Screened out/refused in SMS

CO1. To make sure my computer record is correct, may I confirm the spelling of your child’s name?

First Name: (STRING 50)

Middle Initial: (STRING 1)

Last Name: (STRING 50)

HARD CHECK: IF CO1 FIRST OR LAST NAME=NO RESPONSE; You must answer this question to continue to provide consent.

CO2. May I confirm the spelling of your name? By confirming and typing your name, I am electronically signing this consent form on your behalf, stating that you agree for you and your child to take part in this study.

First Name: (STRING 50)

Middle Initial: (STRING 1)

Last Name: (STRING 50)

HARD CHECK: IF CO2 FIRST OR LAST NAME=NO RESPONSE: You must answer this question to continue to provide consent.

CO2a. INTERVIEWER INSTRUCTION: Please enter today’s date below.

| | | / | | | / | | | | |

MONTH DAY YEAR

(RANGE 2021– 2022)

HARD CHECK: IF CO2a MONTH, DAY OR YEAR= NO RESPONSE: You must answer this question to continue to provide consent.

CO4. Next, I have some questions about you and your child. How are you related to [CHILD]?

Select one only

 Mother 11

 Father 12

 Grandmother 17

 Other Guardian (SPECIFY) 21

Specify (STRING 50)

HARD CHECK: IF CO4 = NO RESPONSE: You must answer this question to continue to provide consent.

CO5. What is your home telephone number?

PROGRAMMER: INSERT PHONE MASK

(___) ___-____

 Do not have a home telephone number 0

HARD CHECK: IF CO5=NO RESPONSE; Please provide a telephone number where we can reach you about the study. We will not use your number for any other purposes. To continue to the next question without providing a response, click the Next button.

CO5 HAS PHONE PROVIDED

CO5_HomePhoneTZ. What time zone is that in?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

CO6. Do you have a cellular or other telephone number?

PROGRAMMER: INSERT PHONE MASK

(___) ___-____

 Do not have a cellular/other telephone number 0

HARD CHECK: IF CO6=NO RESPONSE; Please provide a telephone number where we can reach you about the study. We will not use your number for any other purposes. To continue to the next question without providing a response, click the Next button.

CO6 HAS PHONE PROVIDED

CO6_CellPhoneTZ. What time zone is that in?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

CO7. What is your mailing address?

Street Address 1: (STRING 50)

Street Address 2: (STRING 50)

City: (STRING 50)

State: (STRING 2)

Zip: (STRING 9)

NO RESPONSE M

SOFT CHECK: IF CO7=NO RESPONSE: Please provide an answer to this question and continue. To continue to the next question without providing a response, click the Next button.

CO8. What is your email address?

EMAIL

(STRING 50)

 Do not have email 0

HARD CHECK: IF CO8 = NO RESPONSE: Please provide an email address where we can reach you about the study. We will not use your email for any other purposes. If you do not have an email address, mark “do not have email.” You must answer this question to continue to provide consent.

PROGRAMMER INSTRUCTIONS FOR CO10: If “Prefer not to answer” or “Don’t Know” is selected, the other answer options (1, 2, or 3), should be unchecked.

CO10. Is [CHILD] …

Select all that apply

 A boy, 2

 A girl, 1

 Another gender identity (SPECIFY)? 3

(STRING 50)

 Prefer not to answer 4

DON’T KNOW d

NO RESPONSE M

SOFT CHECK: IF CO10= NO RESPONSE; Please provide an answer to this question and continue. To continue to the next question without providing a response, click the Next button.

CO11. May I confirm [CHILD]’s birth date?

| | | / | | | / | | | | |

MONTH DAY YEAR

(RANGE 2014-2019)

NO RESPONSE M

SOFT CHECK: IF CO11 MONTH, DAY, OR YEAR = NO RESPONSE; Please provide an answer to this question and continue. To continue to the next question without providing a response, click the Next button.

CO13. What language would you like to use to complete your survey?

 English 25 GO TO CO_END

 Spanish 33 GO TO CO_END

 Other (SPECIFY) 21 GO TO CO_END

Specify (STRING 50)

NO RESPONSE M GO TO CO_END

SOFT CHECK: IF CO13= NO RESPONSE; Please provide an answer to this question and continue. To complete the consent without providing a response, click the Next button.

ALL

CO_END. Thank you for completing the AIAN FACES consent process with me. Your form has now been submitted. We will send a copy of the consent form to the email address you provided and contact you about the spring 2022 survey soon.

PRIOR TO SURVEY LAUNCH: I can schedule an appointment for us to call you to do the survey once it launches. When would be a good time for me to call back?

AFTER SURVEY LAUNCH: Would you like to complete your survey over the phone now?

(IF NOT A GOOD TIME NOW) When would be a good time for me to call back?

AIAN FACES 2019 Special Parent Consent Form
for Spring 2022 Data Collection: Hard Copy

A IAN FACES SPECIAL PARENT CONSENT FORM FOR SPRING 2022 DATA COLLECTION

We invite you and your child to take part in the American Indian and Alaska Native Head Start Family and Child Experiences Survey, known as AIAN FACES, spring 2022 data collection. AIAN FACES describes children and families participating in Head Start and their Region XI AIAN Head Start programs. Head Start will use the information gained from AIAN FACES to understand the unique needs of families two years after the COVID-19 pandemic began. We are inviting you and your child to participate because your child attends a Head Start program included in the AIAN FACES study. The Administration for Children and Families, part of the U.S. Department of Health and Human Services, is paying for AIAN FACES. Mathematica, an independent firm, is doing the study. Mathematica has worked with directors of Head Start programs in AIAN communities, the OHS leadership and other federal staff, and child development researchers to make sure the study meets the unique needs of AIAN Head Start programs.

If you agree to take part…

We will ask you to complete a survey soon via the web or over the phone. We will ask you about your child, your family’s activities and routines (such as eating meals together), your feelings, and your well-being during the COVID-19 pandemic. The survey will take about 40 minutes.

We will ask your child’s Head Start teacher some questions about your child in a teacher-child report. It will have questions about your child’s behavior, skills, and any special concerns or disabilities. This will help us learn more about how your child is doing in Head Start.

We will offer a gift card for your help. You will have the option to do the survey by phone or on the web soon. After you finish the survey, as a thank you, we will send you a $30 gift card.

You can choose whether you and your child will be part of the study. Taking part is completely voluntary. There are no risks or direct benefits from taking part in the study. 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 outside of the Mathematica study team will be able to connect you to the answers you provide to the survey questions. Some questions might ask you to answer questions in your own words. We may use statements or parts of statements you make in connection with the study; however, we will not identify you as the source of the statement; we also will not identify your program or community. We never identify you or any other individual parent, child, or staff member in any report; reports contain only general study results. All information collected as part of AIAN FACES 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) will be securely shared only with qualified individuals who are studying Head Start children, their families, and programs.

We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us protect your privacy. This strictly limits when the study team can 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 AIAN FACES, please call the study staff including Sara Skidmore, the survey director, toll free at 833-961-2894. A staff member will be happy to talk with you. You may also call this number to complete the consent form over the phone. You can find out more about AIAN FACES on the study website at https://www.acf.hhs.gov/opre/project/american-indian-and-alaska-native-head-start-family-and-child-experiences-survey-ai-0.

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. You may also provide consent online and complete your survey by scanning the QR code below with your smartphone’s camera or visiting the following website:

Thank you! [LINK]

[QR CODE]

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

I agree to have AIAN FACES 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 completing a survey this spring. Some questions might ask me to answer questions in my own words. The study may use statement(s) or parts of statements I make in connection with the study; however, I will not be identified as the source of the statement; the study also will not identify my program or community. I will receive a $30 gift card after I fill out the survey this spring. If I choose to take part in the study but then decide I want to leave the study at any point, that is okay.

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 ( )___________________

7. Address :

Address 1 Address 2

City State Zip

8. Email address

9. Is child…  A boy  A girl  Another gender identity  Prefer not to answer

10. Child’s birthday

Month Day Year

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

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to provide descriptive information about Head Start programs and the families they serve. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: 0970-0151, Exp: 12/31/2023. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Lizabeth Malone, Mathematica, 1100 1st Street, NE, 12th Floor, Washington, DC 20002.

Mathematica 1