consent form

P.O. Box 2393

Princeton, NJ 08543-2393

Telephone (609) 799-3535

Fax (609) 799-0005

www.mathematica-mpr.com

Spring 2009

BABY FACES 2009 CONSENT FORM

We are inviting you and your child to participate in the Early Head Start Family and Child Experiences Survey (Baby FACES). The purpose of Baby FACES is to learn more about families in Early Head Start and the kinds of services Early Head Start provides to families with infants and toddlers. Information from this study will be used to help Early Head Start better serve all children and their families. Baby FACES is sponsored by the Administration for Children and Families of the U.S. Department of Health and Human Services and is being conducted by Mathematica Policy Research, Inc. (MPR), an independent research company.

If you agree to participate and are one of the families selected for the study…

We will interview you in spring 2009, and each spring until your child is 3 years old. We will ask you questions about the kinds of things your child can do, about your family’s activities and routines, about your feelings, and about your health. These interviews will take about one hour and will be conducted in your language. We will give you $35 after each interview to thank you for your help.

We will do some activities with your child so we can find out how Early Head Start helps children learn and grow. When your child is age 2 and again at age 3, we will ask him or her to take part in some fun activities, such as doing a puzzle, with a trained researcher. These activities take about 30 minutes. Your child will receive as a special gift as a thank-you.

We will ask your child’s Early Head Start teachers or home visitors some questions so that we can learn more about the progress your child is making.

You can choose whether you and your child will be part of the study. Your participation is completely voluntary. Your decision will not influence the Early Head Start services you and your child are receiving. No one from the Early Head Start program will see or hear your answers or be informed about how your child does on the activities. All of the study results will be reported for groups of parents and children, and no results will be reported for individuals. There is one exception—if we learn that a child has been abused or is endangered, we are required by law to report this to the appropriate authorities, which could result in official action in accordance with state law.

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If you have any questions about the Baby FACES study, please call Cassandra Meagher, Survey Director, toll free at xxx-xxx-xxxx. If you have any questions about your rights as a research volunteer, please call [NAME} toll free at xxx-xxx-xxxx.

Please sign the enclosed consent form and give it to your Early Head Start home visitor or teacher. Thank you for helping us.

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

I agree that my child and I will participate in this study. I also agree to have Baby FACES researchers collect some information from my child’s home visitors or teachers in Early Head Start. I will be paid $35 each time I am interviewed, and I will also receive a gift for my child each time my child is assessed. I may withdraw this consent at any time without penalty.

Signature of Parent/Guardian who will participate in this interview:			Date: | | | / | | | / | | | Month Day Year
Printed Name of Parent/Guardian who will participate in the interview: (Print)
Relationship to Child:	 Mother  Father  Grandmother  Other Guardian
Child’s Name: (Print)			Child’s Birthday: | | | / | | | / | | | Month Day Year
What language does your child use most often at home?
 English	 Spanish	 Other
Please telephone me at this number to make my appointment: ( ) - Area Code
Please interview me in:
 English	 Spanish	 Other

To help us arrange for your interview, please circle the times you are usually available.

please circle more than one time
Monday	Tuesday	Wednesday	Thursday	Friday
7:00 AM – 10:00 AM	7:00 AM – 10:00 AM	7:00 AM – 10:00 AM	7:00 AM – 10:00 AM	7:00 AM – 10:00 AM
10:00 AM – 1:00 PM	10:00 AM – 1:00 PM	10:00 AM – 1:00 PM	10:00 AM – 1:00 PM	10:00 AM – 1:00 PM
1:00 PM – 5:00 PM	1:00 PM – 5:00 PM	1:00 PM – 5:00 PM	1:00 PM – 5:00 PM	1:00 PM – 5:00 PM
5:00 PM – 7:00 PM	5:00 PM – 7:00 PM	5:00 PM – 7:00 PM	5:00 PM – 7:00 PM	5:00 PM – 7:00 PM
After 7:00 PM	After 7:00 PM	After 7:00 PM	After 7:00 PM	After 7:00 PM

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White Copy to MPR Yellow Copy to On-Site Coordinator Pink Copy to Parent