DCFS Youth Interview

OMB NO: 0970-0408
EXPIRATION DATE: xxxxxxx

C9. DCFS Youth Assent and Interview

Youth Assent (ages 11-16)

Westat, a research company, is inviting you to take part in a research study about services you are getting from the Illinois Department of Children and Family Services (DCFS). You do not have to be in the study. It is up to you. A researcher will review this form with you before you decide whether to take part or not.

What is a research study?

A study collects information so people can understand something better.

Why is Westat doing this study?

We want to find out if the services you receive help you and your family. If they do, they may also help other children and families.

What will happen if I am in this study?

If you are okay with taking part in the study, you will meet in a private place with a researcher to answer questions about yourself and your family. The researcher will then come back 6 months later and you will be asked similar questions. The questions will take about 45 minutes to answer. There are no right and wrong answers.

For your privacy, you will use a computer to answer the questions. If you need help using the computer or answering the questions, you can ask the researcher questions at any time during the interview.

Do I get anything for being in the study?

Yes. You will get a $20 gift card each time you take part in an interview.

There are no direct benefits to you in taking part in the interviews. But, taking part will help DCFS come up with better ways to serve children and families.

Are there any risks to being in the study?

Talking about family can sometimes make people feel sad. If any of the questions make you feel upset or sad, you can ask to skip those questions. You can also talk with your caseworker if you are still feeling sad or upset after your meeting with the researcher. You can end the meeting with the researcher at any time.

Will what I share during the study be kept private?

We will keep what you tell us private to the extent permitted by law. We will combine what you tell us with what other kids tell us when we write reports about the study. No names will be in these reports.

To help protect your privacy, the government has provided the research team a Certificate of Confidentiality. With this Certificate, we do not have to tell people that you took part in the study or share with others any of the information that you tell us. However, if you tell us that someone has hurt you or that you want to hurt yourself or someone else, we have to tell the authorities. We may also need to share some of your answers with your therapist so that he or she can better serve you.

To make sure the researchers are following rules when asking you questions, someone may ask to sit in on your interview. If someone wants to sit in, the researcher will let you know and ask you to agree first.

Do I have to be in the study?

The DCFS guardian has given consent for us to talk to you, but you can choose not to talk to us. No one will get mad at you if you do not want to be in the study. Your decision will not change the services you currently get.

What if I have questions?

If you have questions right now, please talk to the person who reviews this form with you. You can also call the people below.

If you have any questions about the study, please contact: Raquel Ellis, Westat Study Contact 1-800-WESTAT1 (937-8281), x5173 raquelellis@westat.com

For questions about the your rights as a participant in this study, contact: The Westat Institutional Review Board (IRB) Administrator, 1-800-WESTAT1 (937-8281), x8828

SIGNATURE

Signing this form means that you read or listened to someone read this form to you, you understand what it says, and you agree to take part in the study. You will receive a copy of this form. If you do not want to take part in the study, please let the researcher know.

___________________________________

Child’s Signature

_____________________________________

Print Name

___________________________________

Date

FOR RESEARCH STAFF USE ONLY
Youth declined to participate in data collection.

Abbreviated Dysregulation Inventory Instructions on the ACASI screen: Thank you for agreeing to complete the interview. You will be asked questions about you and your family. There are no right or wrong answers to these questions; we only ask that you answer them honestly. There are five sections. At the beginning of each section, you will be told how to complete the questions that follow. You will see one question at a time. You can choose to answer questions on your own or ask for help. At any time, you can let the interviewer know if you have questions, need a break, skip questions, or would like to end your participation. The first few questions show you how this work. Click “NEXT” to move to the next screen.
		Never True	Occasionally True	Mostly True	Always True
1.	I have trouble controlling my temper.	0	1	2	3
2.	I have difficulty remaining seated at school or at home during dinner.	0	1	2	3
3.	I develop a plan for all my important goals.	0	1	2	3
4.	I lose sleep because I worry.	0	1	2	3
5.	I get very fidgety after a few minutes if I am supposed to sit still.	0	1	2	3
6.	I put my plans into action.	0	1	2	3
7.	When I am angry I lose control over my actions.	0	1	2	3
8.	I have difficulty keeping attention on tasks.	0	1	2	3
9.	I think about the future consequences of my actions.	0	1	2	3
10.	I get so frustrated that I often feel like a bomb ready to explode.	0	1	2	3
11.	I get into arguments when people disagree with me.	0	1	2	3
12.	Once I have a goal I make a plan to reach it.	0	1	2	3
13.	I fly off the handle for no good reason.	0	1	2	3
14.	Little things or distractions throw me off.	0	1	2	3
15.	As soon as I see things are not working, I do something about it.	0	1	2	3
16.	There are days when I'm "on edge" all the time.	0	1	2	3
17.	I can’t seem to stop moving.	0	1	2	3
18.	I consider what will happen before I make a plan.	0	1	2	3
19.	I easily become emotionally upset when I am tired.	0	1	2	3
20.	Most of the time I don't pay attention to what I am doing.	0	1	2	3
21.	I think about my mistakes to make sure they don't happen again.	0	1	2	3
22.	Often I am afraid I will lose control of my feelings	0	1	2	3
23.	I get bored easily.	0	1	2	3
24.	I spend time thinking about how to reach my goals.	0	1	2	3
25.	I slam doors when I am mad.	0	1	2	3
26.	I am easily distracted.	0	1	2	3
27.	Failure at a task or in school makes me work harder.	0	1	2	3
28.	My mood goes up and down without reason.	0	1	2	3
29.	I spend money without thinking about it first.	0	1	2	3
30.	I stick to a task until it is finished.	0	1	2	3

Youth Social Support Instrument

This set of questions is about the support you receive from family members, friends, and people in your community. Please choose the response that best represents your answer to the question.

1. Is there an adult (or adults) you can turn to for help if you have a serious problem?

__ NO (0) (Skip to 3)

__ YES (1)

2a. Could you go to a parent or someone who is like a parent, with a serious problem?

__ NO (0)

__ YES (1)

2b. Could you go to another relative (not a parent), with a serious problem?

__ NO (0)

__ YES (1)

2c. Could you go to another adult (not a relative), with a serious problem?

__ NO (0)

__ YES (1)

2d. Could you go to a friend or relative about your age with a serious problem?

__ NO (0)

__ YES (1)

3. In the 6 months, has there been an adult, OUTSIDE OF YOUR FAMILY, who

has encouraged you and believed in you?

__ NO (0) (Skip to 4)

__ YES (1)

3a. Would you say this has made a difference in your life?

__ NO (0)

__ YES (1)

4. In the past 6 months, has there been an adult WITHIN YOUR FAMILY, who has

encouraged you and believed in you?

__NO (Skip to 5)

__YES

4a. Would you say this has made a difference in your life?

__NO

__YES

Think about the adult in your life, other than a parent or guardian, who you have felt closest to or who has helped you the most.

5. Who is this adult?

1 - Your grandfather

2 - Your grandmother

3 - Another relative

4 - A teacher, coach, or other adult at school

5 - Another adult

6 - There is no one like this (skip to next form)

5. How old were you when {HE/ SHE} first became important in your life?

1. 0 –1 year old 10 - 10 years

2. 2 years 11 - 11 years

3. 3 years 12 - 12 years

4. 4 years 13 - 13 years

5. 5 years 14 - 14 years

6. 6 years 15 - 15 years

7. 7 years 16 - 16 years

8. 8 years 17 - 17 years

9. 9 years 18 - 18 or more years

7. Is this person still living?

0 - No

1 - Yes

9 - I don’t know

If answer is 0 or 9, skip to 11

If answer is 1, skip question 11

8. Is {HE/ SHE} still important to you?

0 - No

1 - Yes

9. How often do you see {HIM/ HER}?

1 - Less than once a year

2 - About once a year to every few months

3 - About once a month to once a week

4 - Two to five times a week

5 - Almost every day

9. How often do you communicate with {HIM/ HER} in other ways, like

talking on the phone, sending emails, or writing letters?

1 - Less than once a year

2 - About once a year to every few months

3 - About once a month to once a week

4 - Two to five times a week

5 - Almost every day

11. How old were you the last time you had contact with {HIM/ HER}?

1 - 0 – 1 year old 10 - 10 years

2 - 2 years 11 - 11 years

3 - 3 years 12 - 12 years

4 - 4 years 13 - 13 years

5 - 5 years 14 - 14 years

6 - 6 years 15 - 15 years

7 - 7 years 16 - 16 years

8 - 8 years 17 - 17 years

9 - 9 years 18 - 18 or more years

How much did {HE/ SHE} do the following:

12a. Showed that s/he cared about you and was there to listen when you needed

to talk to someone?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

12b. Taught you things, showed you how to do things, or helped you with

something you were working on?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

How much did {HE/ SHE} do the following:

12c. Spent time with you talking or doing things, or going places with you for

fun?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

12d. Helped you solve problems, or helped you find a way to do something you

wanted to do?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

12e. Helped get you things you needed, took you places you needed to go, or gave

you money?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

13. How close do/did you feel to {HIM/ HER}?

1 - Extremely close

2 - Quite close

3 - Somewhat close

4 - Not very close

Trauma Symptom Checklist for Children (TSCC) – Alternative Version

Approval is underway to use this instrument. It is designed to assess distress and related symptoms after an acute or chronic trauma including Anxiety, Depression, Anger, Posttraumatic Stress, and Dissociation.

Parent Contact with Youth Instrument¹

The next group of questions is about contact with the parent(s) that your caseworker is working to bring you back together with.

1) First, did you visit with your mother in the past month, or since [insert date from 1 month ago]?

_____ YES

_____ NO

 1a) IF YES: How many visits did you have with your mother in the past month?

            _________ VISITS

2) Did you have other contact with her in the past month, like phone calls, letters, emails, texting, or contact on Facebook?

_____ YES

_____ NO

 2a)   IF YES: In the past month, how often did you have …

Phone calls with your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters sent to your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters received from your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Email exchanges with your mother?

 _____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Text exchanges with your mother?

 _____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Facebook contacts with your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

3) How satisfied are you with this level of visits and contact? Would you say it is…

                        _____ Not enough contact,

                        _____ Just the right amount contact, or

                        _____ Too much contact?

4) Did you visit with your father in the past month?

_____ YES

_____ NO

4a) IF YES: How many visits did you have with him in the past month?

_______ VISITS

5) Did you have other contact with him in the past month, like phone calls, letters, emails, texting, or contact on Facebook?

_____ YES

_____ NO         

IF YES: In the past month, how often did you have …

Phone calls with your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters sent to your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters received from your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Email exchanges with your father?

 _____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Text exchanges with your father?

 _____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Facebook contacts with your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

6) How satisfied are you with this level of visits and contact? Would you say it is…

                        _____ Not enough contact,

                        _____ Just the right amount contact, or

                        _____ Too much contact?

Emotional Permanency Questions²

The next set of questions are about how supported you feel by people in your life.  Choose a response that best describes how much you agree or disagree with each statement.

1) I have people who expect me to always spend holidays like Christmas and Thanksgiving with them.
   ____ Strongly Agree
   ____ Somewhat Agree
   ____ Somewhat Disagree
   ____ Strongly Disagree

2) At important events like graduations, I am not sure if there will be people there to celebrate with me.
   ____ Strongly Agree
   ____ Somewhat Agree
   ____ Somewhat Disagree
   ____ Strongly Disagree

3) I know someone I could always go to if I needed a place to sleep, even if it was in the middle of the night.
   ____ Strongly Agree
   ____ Somewhat Agree
   ____ Somewhat Disagree
   ____ Strongly Disagree

4) I have adults in my life who I can call at any time if I needed something.

____ Strongly Agree

____ Somewhat Agree

____ Somewhat Disagree

____ Strongly Disagree

1 The questions are from the current Illinois Adult Connections Study.

2 Questions 1-3 are from the current Illinois Adult Connections Study and question 4 is a modified question from the Supportive Connections Inventory being used in the Arizona PII evaluation.

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.