Appendix A-1_Consent for Directors

Appendix A-1:

Consent form for Directors

CONSENT FORM

Westat is conducting a study called the Family and Early Care and Education Provider Relationship Study for the U.S. Department of Health and Human Services. The goal of the study is to develop a measure of relationships between parents and those that teach and care for their children. The results will help develop surveys that teachers, child care providers, and policymakers can use to improve children’s care and education. We are asking you to fill out a survey which will ask questions about your early education or child care program. We are also asking your permission to speak with teachers and/or child care providers and parents from within your program about participating in the study.

• Your survey should take about 10 minutes to complete. Surveys for parents and child care providers/teachers will also take about 10 minutes each to complete.

• Participation is completely voluntary. You may stop at any time, and you do not have to answer any questions you do not wish to answer.

• All information obtained from this study will be kept private and will only be seen by people authorized to work on this project. The report summarizing the findings will not contain any names or identifying information.

• As part of this study you will be asked to allow the study’s representative to post flyers and talk with child care providers/teachers about participating in the study.

• You will receive a check for $50 as a token of our appreciation for completing the survey and allowing the study to speak with child care providers/teachers and parents.

If you agree to participate in the study, please sign the following statement:

I have read this consent form and understand the proposed project. I have consented to participate in this study.

________________________ ___________

Signature Date

________________________

Printed Name

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 number.

The office of Management and Budget has approved the data collection under OMB #XXXX-XXXX. OPRE is authorized to conduct this study under Section 649 of the Head Start Act, as amended by the Improving Head Start for School Readiness Act of 2007, codified at 42 United States Code (U.S.C.) 9844.

OMB No.: XXXX-XXXX Expiration date: XX/XXXX