Appendix F: Consent

Appendix F

Consent

Contents

Appendix F.1 Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study provider consent letter and consent form 2

Appendix F.2 Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study family consent letter and consent form 6

Appendix F.1

Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study provider consent letter and consent form

Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study provider consent letter

The Home-Based Child Care Toolkit for Nurturing School-Age Children (HBCC-NSAC Toolkit) Pilot Study is conducted by Mathematica and the Erikson Institute for the Office of Planning, Research, and Evaluation (OPRE) within the Administration for Children and Families (ACF) at the U.S. Department of Health & Human Services. We are developing the HBCC-NSAC Toolkit that HBCC providers can use to help identify strengths and areas for growth in providing care for children and partnering with their families. The HBCC-NSAC Toolkit is for HBCC providers who are at least 18 years old and who care for at least one school-age child (age 5 and in kindergarten, or ages 6 through 12) for at least 10 hours per week. These providers may also care for under school-age children (ages birth through 5 and not yet in kindergarten).

We invite you to take part in the HBCC-NSAC Toolkit Pilot Study. Study activities consist of:

1. A 20-minute telephone call that you completed with a study team member who explained the study and talked about your interest in and eligibility for the study.

2. Completing the HBCC-NSAC Toolkit provider questionnaire, which will take about [IF PHASE ONE: 45] [IF PHASE TWO 30] minutes.

3. [IF PHASE ONE: A 30-minute WebEx call with a study team member to share your thoughts about the HBCC-NSAC Toolkit provider questionnaire.]

4. A 15-minute telephone call with a study team member who will discuss logistics about the family questionnaire and ask you to invite family member(s) of school-age children in your care to complete it, [IF PHASE ONE:, and participate in a WebEx call to discuss their experience completing it].

In total, your participation will take about [IF PHASE ONE: 2 hours] [IF PHASE TWO: 1 hour]. You will receive a [IF PHASE ONE: $75] [IF PHASE TWO: $50] gift card as a thank you. If you complete the family questionnaire call with the study team member and agree to share the family questionnaire with families, we will send you an additional $10 gift card as a thank you.

Your participation is completely voluntary. You can choose to not respond to any question if you wish. There are no right or wrong answers to any of the questions. You may withdraw from the study at any point without consequences. There are no benefits or risks to participation.

We will keep your responses private. We will not share your responses with others who participate in the study, including family members of the children in your care.

We will produce internal reports for ACF that will describe what we learn from responses to the provider questionnaire [IF PHASE ONE: and WebEx calls] as a group, and we will not quote or name specific people.

[IF PHASE ONE: With your permission, we will record the WebEx calls. This information is meant to serve as a record of your responses and it will not be shared outside the study team. If you want to say anything that you don’t want recorded, we can pause the recording during the call. We will delete all recordings at the end of the study (after the analysis of responses from all participating respondents is finished).]

We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us protect your privacy by limiting when the study team can give out information that identifies you, but there are a few exceptions. For example, if you indicate that you are planning to harm yourself or others, we may be required by law to share that with the appropriate authorities. The U.S. Department of Health and Human Services (DHHS) may ask for data for an audit or evaluation. If they do, we will need to provide it. However, only DHHS staff involved in the review will see it.

If you have any questions about the HBCC-NSAC Toolkit Pilot Study, you may contact the project director, Patricia Del Grosso, at pdelgrosso@mathematica-mpr.com or (609) 945-6580. This study has been reviewed and approved by the Health Media Lab Institutional Review Board (HML IRB).

The referenced collection of information is voluntary. Information will be kept private. 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 control number for this collection is 0970-0355 and the expiration date is 8/31/2024.

The Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study provider consent form

I understand the contents of the Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study provider consent letter. I understand what I will be asked to do and I agree to participate in the study.

Provider name (print) ______________________________

Provider Signature ________________________________ Date ________________

The referenced collection of information is voluntary. Information will be kept private. 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 control number for this collection is 0970-0355 and the expiration date is 8/31/2024.

Appendix F.2

Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study family consent letter and consent form

The Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study family consent letter

The Home-Based Child Care Toolkit for Nurturing School-Age Children (HBCC-NSAC Toolkit) Pilot Study is conducted by Mathematica and the Erikson Institute for the Office of Planning, Research, and Evaluation (OPRE), within the Administration for Children and Families (ACF) at the U.S. Department of Health & Human Services. We are developing the HBCC-NSAC Toolkit that HBCC providers can use to help identify their strengths and any areas for growth in how they care for children and partner with children’s families. As part of the study, we want to talk to families with school-age children (age 5 and in kindergarten, or 6 through 12) who receive care in a home, for example, from a licensed family child care provider or from a family member, friend, or neighbor. By families, we mean the person most responsible for the care of the school-age child when they are not in child-care (for example, the child’s parent or guardian). This person should be 18 years old or older.

We invite you, the child’s primary caregiver, to take part in the HBCC-NSAC Toolkit Pilot Study. As part of the study, you will complete the family questionnaire part of the HBCC-NSAC Toolkit that asks about child care topics, like routines and types of interactions with children, that families think are important to talk about with their provider. Completing the family questionnaire will take about 10 minutes. [IF PHASE ONE: Once you complete the family questionnaire, we will contact you to schedule a 30-minute WebEx call to ask you about your experience answering the family questionnaire]. In total, your participation will take [IF PHASE ONE: 40] [IF PHASE TWO: 10] minutes. You will receive a [IF PHASE ONE: $35] [IF PHASE TWO: $10] gift card as a thank you.

You will return the completed questionnaire to your child’s HBCC provider using a self-seal envelope provided by the study team. Your child’s provider will know that you participated in the study, but your child’s provider will not know how you responded to the questionnaire if you seal your completed questionnaire inside the envelope before returning it to your child’s provider.

Your participation is completely voluntary. You can choose to not respond to any question if you wish. There are no right or wrong answers to any of the questions. You may withdraw from the study at any point without consequences. There are no benefits or risks to participation.

We will keep your responses private. We will not share your responses with others who participate in the study, including the child care provider who cares for your child(ren).

We will produce internal reports for ACF that will describe what we learn from responses to the family questionnaire [IF PHASE ONE: and WebEx calls] as a group, but we will not quote or attribute comments to specific people by name.

[IF PHASE ONE: With your permission, we will record the WebEx calls. This information is meant to serve as a record of your responses and it will not be shared outside the study team. If you want to say anything that you don’t want recorded, we can pause the recording during the call. We will delete all recordings at the end of the study (after the analysis of responses from all participating respondents is finished.]

We have a Certificate of Confidentiality from the National Institutes of Health. The Certificate helps us protect your privacy by limiting when the study team can give out information that identifies you, but there are a few exceptions. For example, if you indicate that you are planning to harm yourself or others, we may be required by law to share that with the appropriate authorities. The U.S. Department of Health and Human Services (DHHS) may ask for data for an audit or evaluation. If they do, we will need to provide it. However, only DHHS staff involved in the review will see it.

If you have any questions about the HBCC-NSAC Toolkit Pilot Study, you may contact the project director, Patricia Del Grosso, at pdelgrosso@mathematica-mpr.com or (609) 945-6580. This study has been reviewed and approved by the Health Media Lab Institutional Review Board (HML IRB).

The referenced collection of information is voluntary. Information will be kept private. 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 control number for this collection is 0970-0355 and the expiration date is 8/31/2024.

The Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study family consent form

I am 18 years old or older, and I am a primary caregiver for a school-age child in home-based child care.

I understand the contents of the Nurturing School-Age Children in Home-Based Child Care Pilot Study family consent letter. I understand what I will be asked to do and I agree to participate in the study.

Primary caregiver name (print) ____________________________­­­_________­­­

Primary caregiver phone number (print) ______________________________

Primary caregiver email address (print) _______________________________

Primary caregiver mailing address (print):

Street: ___________________________­­­­­________­

City: _______________________­­­­­_____________

State: ____________________________________

Zip: _____________________________________

Primary caregiver signature ________________________________ Date ________________

The referenced collection of information is voluntary. Information will be kept private. 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 control number for this collection is 0970-0355 and the expiration date is 8/31/2024.