Direct Assessment Consent Form

APPENDIX A

Parent Informed Consent for Videotaping Child Activities

Description of Videotaping Procedures for Child Activities

As we discussed earlier, we will be conducting several activities directly with your child as part of the study of Early Head Start (EHS). The activities will take approximately 30 to 40 minutes, depending on your child’s age. We will be asking your child to do things like naming objects, identifying letters and words, and counting objects. We will also play games where your child is asked to draw circles, to walk along a line on the floor, and to wait to get a present until it is wrapped. Each child will be asked to play some, but not all, of these activities.

We would like to videotape the interviewer and your child during these activities. The videotaped information will be reviewed by the researchers to monitor and review the interviewer’s performance. The videotape will be reviewed only to see if the interviewer conducts the activities correctly. The videotape will not be reviewed to see how your child does on the activities.

There are no known risks of videotaping the activities to you or your child. Your child’s participation in the videotaping is voluntary. You, or your child, may refuse to be videotaped during any or all parts of these activities, or stop the videotape at any time.

Privacy

The videotaped information, and all the other information collected, will be kept private to the extent permitted by law. In other words, no one other than the researchers will see the videotaped information that we are getting from you today. All the videotapes will be kept in locked cabinets. The videotapes will not be edited or copied. All the videotapes will be destroyed upon completion of the study. Your child’s image, voice, and first name will be on the videotape, but no identifying information, such as full name and address, will be released to anyone, except as required by law. The research team will combine your information with information from all of the other participants to create group statistics. Although every effort will be made to keep research records private, there may be times when federal or state law requires the disclosure of such records, including personal information. This is very unlikely, but if disclosure is ever required, the research team will take all steps allowable by law to protect the privacy of personal information.

Exceptions to Privacy

There are some exceptions to our promise to keep this information private. If you or your child tells us that you or your child are in immediate danger, or that you or your child intend to harm yourself or someone else, we may need to inform the appropriate authorities according to state and local law.

Statement

“I have read this form, or had it read to me. I know that the videotaped information will be reviewed for the sole purpose of monitoring the interviewer’s performance and that all videotaped information will be kept private to the extent allowed by law. I also understand that I, or my child, can refuse to be videotaped at any time without penalty. I agree to permit the voice and image of my child, or the child in my care, to be videotaped.”

Child’s Name Printed

Child’s Legal Parent or Guardian Name Printed Relationship to Child

Signature of Child’s Legal Parent or Guardian Date

If you have any questions about the videotaping procedures, please contact Dr. Pamela Morris, MDRC Senior Research Associate at MDRC, at 212-532-3200.

KS/MO: Video-ICF, ver.4, 11/05/07