Instrument 3: Parent consent form

ATTACHMENT 3. PARENT CONSENT FORM

P.O. Box 2393
Princeton, NJ 08543-2393
Telephone (609) 799-3535
Fax (609) 799-0005
www.mathematica-mpr.com

BABY FACES SPRING 2020 CONSENT LETTER (CENTER-BASED FAMILIES)
We invite you and your child to take part in the Early Head Start Family and Child Experiences Survey
2020 (Baby FACES). We are inviting you because your child is in an Early Head Start program that is
participating in this study.
Baby FACES seeks to learn more about the families in Early Head Start and about the kinds of services
Early Head Start provides to families with infants and toddlers. This study will help Early Head Start serve all
children and their families better. The Administration for Children and Families, part of the U.S. Department
of Health and Human Services (DHHS), is funding Baby FACES. Mathematica Policy Research, an
independent firm, is conducting the study.
If you agree to participate in this study…
We will interview you by phone. We will ask you questions about your family’s activities and routines,
about your feelings, and about your health. We will also ask you to fill out a short questionnaire about the
kinds of things your child can do. The telephone interview will take about half an hour, and the written
questionnaire will take closer to 15 minutes. Both will be in either English or Spanish. As a thank you for
your help, we will give you $25 after you complete the interview and fill out the questionnaire.
We will ask your child’s Early Head Start teacher some questions, and we will conduct an
observation of that classroom. You can choose whether you and your child will be part of the study. Your
participation is completely voluntary. There are no direct risks or benefits to participating. All information
collected during the course of Baby FACES will be kept private to the extent permitted by law. Your choice
will not affect the Early Head Start services you and your child receive. If at any point you decide to leave
the study that is okay. No one from Early Head Start will see or hear your answers. We will only report the
results for parents and children as a group. We will combine all the information we collect without your
name or other identifying information, to use in future research. No one will be able to know that you
participated in this study or find out what answers you gave.
We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us
protect your privacy. This means no one can force the study team to give out information that identifies you,
even in court. However, we may need to share your information if it shows a serious threat to you or to
others, including reporting to authorities when required by law. The United States government may still
request information for an audit.
Baby FACES has been given Institutional Review Board (IRB) approval by Health Media Lab
Institutional Review Board. If you have any questions about the Baby FACES study or about your rights as a
research participant, please call Laura Kalb, the survey director, toll free at 1-833-763-2178.
We hope you will agree to help us with this with this important project. Please sign the enclosed consent form
and return it to your child’s teacher right away or complete the consent form at
https://BabyFacesStudy.com/Consent and let your teacher know that you have provided consent online.
Thank you!

An Affirmative Action/Equal Opportunity Employer

P.O. Box 2393
Princeton, NJ 08543-2393
Telephone (609) 799-3535
Fax (609) 799-0005
www.mathematica-mpr.com

BABY FACES SPRING 2020 CONSENT LETTER (HOME-BASED FAMILIES)
We invite you and your child to take part in the Early Head Start Family and Child Experiences Survey
2020 (Baby FACES). We are inviting you because your child is in an Early Head Start program that is
participating in this study.
Baby FACES seeks to learn more about the families in Early Head Start and about the kinds of services
Early Head Start provides to families with infants and toddlers. This study will help Early Head Start serve all
children and their families better. The Administration for Children and Families, part of the U.S. Department
of Health and Human Services (DHHS), is funding Baby FACES. Mathematica Policy Research, an
independent firm, is conducting the study.
If you agree to participate in this study…
We will interview you by phone. We will ask you questions about your family’s activities and routines,
about your feelings, and about your health. We will also ask you to fill out a short questionnaire about the
kinds of things your child can do. The telephone interview will take about half an hour, and the written
questionnaire will take closer to 15 minutes. Both will be in either English or Spanish. As a thank you for
your help, we will give you $25 after you complete the interview and fill out the questionnaire.
We will ask your child’s Early Head Start home visitor some questions about your family and her
experiences working with you and your child.
We would like to visit your home and ask you to do a short activity with your child that we will video
record. While we are in your home, we will also observe and audio record one of your home visits. We will
archive the video and audio recordings for future research. We will give you $35 to thank you for letting us
come into your home for these activities.
You can choose whether you and your child will be part of the study. Your participation is
completely voluntary. There are no direct risks or benefits to participating. All information collected during
the course of Baby FACES will be kept private to the extent permitted by law. Your choice will not affect
the Early Head Start services you and your child receive. If at any point you decide to leave the study, that is
okay. No one from Early Head Start will see or hear your answers or be provided with any information about
you or your child. We will only report the results for parents and children as a group. We will combine all
the information we collect without your name or other identifying information, to use in future research. No
one will be able to know that you participated in this study or find out what answers you gave.
We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us
protect your privacy. This means no one can force the study team to give out information that identifies you,
even in court. However, we may need to share your information if it shows a serious threat to you or to
others, including reporting to authorities when required by law. The United States government may still
request information for an audit.
Baby FACES has been given Institutional Review Board (IRB) approval by Health Media Lab
Institutional Review Board. If you have any questions about the Baby FACES study or about your rights as a
research participant, please call Laura Kalb, the survey director, toll free at 1-833-763-2178.

An Affirmative Action/Equal Opportunity Employer

We hope you will agree to help us with this with this important project. Please sign the enclosed consent form
and return it to your child’s home visitor right away or complete the consent form at
https://BabyFacesStudy.com/Consent and let your home visitor know that you have provided consent online.
Thank you!

CONSENT FORM
I have read this consent form and understand what I am being asked to do. I understand that my
child and I will take part in this study. I also agree to have Baby FACES researchers collect some
information from my child’s Early Head Start teacher or home visitor. I also agree to participate
in the study by [1)] completing a survey and a parent-child report[ and 2) permitting Baby FACES
researchers to visit me in my home to video record an activity I conduct with my child and observe
and audio record a home visit]. I understand that I may withdraw this consent at any time without
penalty.

1.

Parent/Guardian Signature: ________________________

2.

Parent/Guardian Name: (PRINT) ____________________________________________________

3.

Relationship to Child: ____________________________________________________________

4.

Home Phone: _______________________

Cell Phone: _______________________________

Email: ______________________________

Permission to text at above number: Yes No

5.

Date: _______________________

Address: _______________________________________________________________________
Street Address

Apt. #

City, State

Zip Code

6.

Child’s Name: (if applicable) (PRINT) _________________________________________________

7.

Child’s Sex: (if applicable)  Male

8.

Child’s Age: (if applicable) _________________________________________________________

9.

Child’s Birthday/Expected Date of Birth: ___________________________________________

 Female

Month

Day

Year

10. What language would you like us to interview you in?
 English

 Spanish

If you prefer to give your consent electronically, please go to https://BabyFacesStudy.com/Consent
Log In ID: XXXXXXXXXXXX

Password: XXXXXXXXXXX

This collection of information is voluntary and will be used to learn more about the experiences of families and children served by the Early Head
Start program. 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 control number. The OMB number and
expiration date for this collection are OMB #: 0970-0354, Exp: 10/31/2021.

MPRID 12345678

[HOME-BASED FAMILIES/CENTER-BASED FAMILIES]