DCFS Foster Parent Interview

OMB NO: 0970-0408
EXPIRATION DATE: xxxxxx

C7. DCFS Foster Parent Consent Form and Interview

Consent Form

Introduction and PURPOSE OF STUDY

The U. S. Department of Health and Human Services has hired Westat, a research company, to study the services Illinois Department of Children and Family Services (DCFS) provides to families. The study will assist us in learning whether the services you and the child in your care receive help children leave foster care sooner. We want your help in finding out if these services work.

We are inviting you to take part in this study because a child currently in your care, [insert child’s name], has been selected to take part in a study. You do not have to be in the study. Even if you agree to be in the study, you can stop being in the study at any time. Your choice will not affect the services that you and the child receive.

Procedures

DCFS assigned the child in your care and the child’s family (using a random process like a coin flip) to get one of two types of services that are meant to help this family and benefit you as well. With either service, a caseworker will continue to meet with you and the child, make home visits, refer you and the child to needed services, and check on how you and the child are doing. However, you may also receive extra services depending on your DCFS assignment. These extra services will focus on improving your understanding of the youth’s emotions and behaviors, improving the way you respond to the youth’s emotions and behaviors, and learn ways to lower your stress. You will be told if you are chosen to receive these extra services.

While you are getting these services, Westat wants to study whether the services you receive help families.

Participating in interviews:

In order to study the services you and the child’s family receive, we need to find out information about you and the child in your care. We are asking you to take part in two in-person interviews: at the start of services and 6 months later. During the interviews, you will answer questions about the supports you have in your life, the way you parent the child in your care, and the behaviors of the child in your care.

The interviews will occur at your home at a time that is best for you. 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. You can also skip questions that you do not want to answer. Each interview will take no more than 45 minutes. There are no right and wrong answers.

Studying your interview responses with DCFS client records:

During the study, Westat researchers will review the information from questions we ask you and will also review information from the records DCFS has. These records have information about the child, the child’s family, services received from DCFS, and the family’s case progress. We are asking if you will agree to let us to study your answers together with the information we get from the family’s DCFS records. We will use this information only for the study.

RISKS

We do not think being in the study has any risk. The interview questions do not include sensitive topics. But, if any of the questions make you feel upset or sad, you can talk with the child’s caseworker. You can also skip questions that you do not want to answer. The researcher also has a list of local mental health agencies that he or she can provide you.

INCENTIVE FOR PARTICIPATING IN THE STUDY

You will receive a $20.00 gift card for taking part in each interview.

BENEFITS FOR PARTICIPATING IN THE STUDY

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

PARTICIPANT and data Privacy

We will keep your information private to the extent permitted by law. We will not include information that names you or your family in any reports; information will only be reported for the entire group of families studied. The information you provide will not be shared with your caseworker. However, it may be shared with a therapist that serves you and/or the child in your care to help with service planning. We will use your information for research only.

To help us keep your information private, we received a Certificate of Confidentiality from the U. S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding or under a court order or subpoena. But, we will in all cases take necessary action, including reporting to authorities, to prevent harm to yourself or others. This includes reporting suspected child abuse or neglect.

To make sure that the researchers are collecting the data right, another researcher may ask to sit in during your interview. We will ask you ahead of time so you can decide if the other researcher can sit in or not.

Voluntary participation

You can decide if you want to take part in the study. You can stop being in the study at any time. Taking part in the study or not will not affect the services that you and the child in your care receives.

CONTACTS FOR QUESTIONS ABOUT THE STUDY

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 below means that you read or listened to someone read this form to you, that 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.

_________________________ ____________________________

Participant’s Signature Participant’s Name

Signing below means that you agree to let Westat study your interview answers with the DCFS records for this child’s family.

_________________________ ____________________________

Participant’s Signature Participant’s Name

_________________________

Date

RESEARCH STAFF USE ONLY
Parent declined to participate in data collection.

Abbreviated Dysregulation Inventory-Parent Version
Instructions on CASI screen:
Thank you for agreeing to complete the interview. You will be asked questions about the supports you have in your life, the way you parent the child in your care, and the behaviors of the child in your care. There are no right or wrong answers to these questions; we only ask that you answer them honestly. There are three sections. At the beginning of each section, there will be instructions on 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 works. Click “NEXT” to move to the next screen.
		Never True	Occasionally True	Mostly True	Always True
1.	The child has trouble controlling his/her temper.	0	1	2	3
2.	The child has difficulty remaining seated at school or at home during dinner.	0	1	2	3
3.	The child develops a plan for all his/her important goals.	0	1	2	3
4.	The child loses sleep because he/she worries.	0	1	2	3
5.	The child gets very fidgety after a few minutes if he/she is supposed to sit still.	0	1	2	3
6.	The child put his or her plans into action.	0	1	2	3
7.	When the child is am angry he/she loses control over his/her actions.	0	1	2	3
8.	The child has difficulty keeping attention on tasks.	0	1	2	3
9.	The child thinks about the future consequences of his/her actions.	0	1	2	3
10.	The child gets so frustrated that he/she often feels like a bomb ready to explode.	0	1	2	3
11.	The child gets into arguments when people disagree with him/her.	0	1	2	3
12.	Once the child has a goal he/she makes a plan to reach it.	0	1	2	3
13.	The child flies off the handle for no good reason.	0	1	2	3
14.	Little things or distractions throw the child off.	0	1	2	3
15.	As soon as the child see things are not working, he/she does something about it.	0	1	2	3
16.	There are days when the child is "on edge" all the time.	0	1	2	3
17.	The child can’t seem to stop moving.	0	1	2	3
18.	The child considers what will happen before he/she makes a plan.	0	1	2	3
19.	The child easily becomes emotionally upset when he/she is tired.	0	1	2	3
20.	Most of the time the child doesn’t pay attention to what he/she is doing.	0	1	2	3
21.	The child thinks about his/her mistakes to make sure they don't happen again.	0	1	2	3
22.	Often the child is afraid he/she will lose control of his/he feelings	0	1	2	3
23.	The child gets bored easily.	0	1	2	3
24.	The child spends time thinking about how to reach his/her goals.	0	1	2	3
25.	The child slams doors when he/she is mad.	0	1	2	3
26.	The child is easily distracted.	0	1	2	3
27.	Failure at a task or in school makes the child work harder.	0	1	2	3
28.	The child’s mood goes up and down without reason.	0	1	2	3
29.	The child spends money without thinking about it first.	0	1	2	3
30.	The child sticks to a task until it is finished.	0	1	2	3

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Social Provisions Scale

Instructions

In answering the next set of questions I am going to ask you, I want you to think about your current relationship with friends, family members, coworkers, community members, and so on. Please tell me to what extent you agree that each statement describes your current relationships with other people. Use the following scale to give me your opinion. (Hand a response card.) So, for example, if you feel a statement is very true of your current relationships, you would tell me “strongly agree”. If you feel a statement clearly does not describe your relationships, you would respond “strongly disagree”. Do you have any questions?

Strongly Disagree Disagree Agree Strongly Agree

1 2 3 4

1. There are people I can depend on to help me if I really need it.
2. I feel that I do not have close personal relationships with other people.
3. There is no one I can turn to for guidance in times of stress.
4. There are people who depend on me for help.
5. There are people who enjoy the same social activities I do.
6. Other people do not view me as competent.
7. I feel personally responsible for the well-being of another person.
8. I feel part of a group of people who share my attitudes and beliefs.
9. I do not think other people respect my skills and abilities.
10. If something went wrong, no one would come to my assistance.
11. I have close relationships that provide me with a sense of emotional security and well-being.
12. There is someone I could talk to about important decisions in my life.
13. I have relationships where my competence and skills are recognized.
14. There is no one who shares my interests and concerns.
15. There is no one who really relies on me for their well-being.
16. There is a trustworthy person I could turn to for advice if I were having problems.
17. I feel a strong emotional bond with at least one other person.
18. There is no one I can depend on for aid if I really need it.
19. There is no one I feel comfortable talking about problems with.
20. There are people who admire my talents and abilities.
21. I lack a feeling of intimacy with another person.
22. There is no one who likes to do the things I do.
23. There are people I can count on in an emergency.
24. No one needs me to care for them.

Parenting Practices Chicago Survey - Parent Version

The following questions have to do with the kinds of things that you and (adolescent’s name) may have talked about, or have done together in the past 2 months. Please choose the response that best represents your answer.

1. When was the last time that you discussed with ______________his/her plans for the coming day?

1. _{Don't know}

2. More than 1 month ago

3. Within the last month

4. Within the last week

5. Yesterday/Today

2. In the past 2 months, about how often have you discussed with his/her plans for the coming day?

1. _{Don't know}

2. _{Less than once a month}

3. _{At least once a month}

4. _{At least once a week}

5. _{Almost every day}

3. When was the last time you talked with about what he/she actually done during the day?

1. _{Don't know}

2. _{More than 1 month ago}

3. _{Within the last month}

4. _{Within the last week}

5. _{5= Yesterday/Today}

4. In the past 2 months, about how often have you talked with about what he/she had actually done during the day?

1. _{Don't know}

2. _{More than 1 month ago}

3. _{Within the last month}

4. _{Within the last week}

5. _{Yesterday/Today}

5. Does ________have a set time to be home on school nights?

1. _{No set time}

2. _{Sometimes set time}

3. _{Always set time}

6. Does ________have a set time to be home on weekend nights?

1. _{No set time}

2. _{Sometimes set time}

3. _{Always set time}

7. Does _________help with family fun activities?

1. _{Hardly ever}

2. _Sometimes

3. _Often

8. Does__________ like to get involved in such family activities?

1. _{Hardly ever}

2. _Sometimes

3. _Often

9. How often do you have time to listen to when he/she wants to talk to you?

1. _{Hardly ever}

2. _Sometimes

3. _Often

10. Do you and do things together at home?

1. _{Hardly ever}

2. _Sometimes

3. _Often

11. Does _____________go with members of the family to movies, sports events, or other outings?

1. _{Hardly ever}

2. _Sometimes

3. _Often

12. How often do you have a friendly talk with ?

1. _{Hardly ever}

2. _Sometimes

3. _Often

13. Does help you with chores, errands and/or other work?

1. _{Hardly ever}

2. _Sometimes

3. _Often

14. Do you talk with about how he/she is doing in school?

1. _{Hardly ever}

2. _Sometimes

3. _Often

15. On average, how much time are you together with the child on weekdays, that is, when you and your child are both awake?

1. _{Less than 30 minutes/day}

2. _{30 minutes to 1 hour}

3. _{More than 1 hour, less than 3}

4. _{3 to 6 hours}

5. _{More than 6 hours}

16. On average, how much time are you together with the child on weekends?

1. _{Less than 30 minutes/day}

2. _{30 minutes to 1 hour}

3. _{More than 1 hour, less than 3}

4. _{3 to 6 hours}

5. _{More than 6 hours}

17. On weekdays, how much of that time are you doing something together, like making something, playing a game, talking, or going out together but not just watching TV?

1. _{Less than 30 minutes/day}

2. _{30 minutes to 1 hour}

3. _{More than 1 hour, less than 3}

4. _{3 to 6 hours}

5. _{More than 6 hours}

18. On weekends, how much of that time are you doing something together, like making something, playing a game, talking, or going out together but not just watching TV?

1. _{Less than 30 minutes/day}

2. _{30 minutes to 1 hour}

3. _{More than 1 hour, less than 3}

4. _{3 to 6 hours}

5. _{More than 6 hours}

19. If __________did not come home by the time that was set, would you know?

1. _{No or very unlikely}

2. _Probably

3. _Certainly

20. When _______is out, do you know what time he/she will be home?

1. _{No or very unlikely}

2. _Probably

3. _Certainly

21. Is it important to you to know what is doing when he/she is outside of the home?

1. _{No, not important}

2. _{Yes, somewhat important}

3. _{Yes, very important}

The following questions ask about where ___________is when he/she is not in school.

22. Where does ______________usually go after school?

1. _{Don't know}

2. _{Somewhere else, unsupervised}

3. _{Home, unsupervised}

4. _{Somewhere else, supervised}

5. _{Home, supervised}

23. Where is he/she usually on weekends?

1. _{Don't know}

2. _{Somewhere else, unsupervised}

3. _{Home, unsupervised}

4. _{Somewhere else, supervised}

5. _{Home, supervised}

24. If you or another adult are not at home, does _______________leave you a note or call you to let you know where he/she is going?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

25. Do you know who _________________'s companions or friends he/she is with when he/she is not at home?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

26. When you are not at home, does _______know how to get in touch with you?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

27. When you and _________________are both at home, do you know what he/she is doing?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

In the past 2 months, when ______________did something that you liked or approved of, how often did you…

28. give him/her a wink or a smile?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

29. say something nice about it; give him/her praise or give approval?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

30. give him/her a hug, pat on the back, or a kiss for it?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

31. give him/her some reward for it, like a present, extra money, or something special to eat?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

32. give him/her a special privilege such as staying up late, or doing some special activity?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

33. do something special together, such as going to the movies, to a game, playing a game, or going somewhere?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

34. Is the discipline you use effective for your son/daughter? Does it work?

1. _{Not really}

2. _{Half of the time}

3. _Usually

35. If your son/daughter is punished, does the punishment work?

1. _{Not really}

2. _{Half of the time}

3. _Usually

36. If you punish___________ does his/her behavior get worse?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

37. Do you hesitate to enforce the rules with _____________because you fear he/she might then harm someone in your household?

4. _{Almost never}

5. _Sometimes

6. _{Almost always}

38. Do you feel that you must be careful not to upset ?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

39. Do you feel that other family members must be careful not to upset _____________?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

40. Do you feel that it is more trouble than it is worth to ask___________ to help you?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

41. Do you think that ________ will take it out on other children if you try to make him/her obey you?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

42. When you are by yourself, do you have much difficulty controlling ________________?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

43. When other adults are present, do you have much difficulty controlling _________________?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

44. Do you leave ____________alone because of his/her moodiness?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

45. Do you think that ______will try to get back at you if you try to make him/her obey you?

1. _{Almost never}

2. _Sometimes

3. _{Almost always}

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.