A Descriptive Study of the Head Start Health Component
U.S. Department of Health and Human Services
Administration on Children, Youth and Families

Consent To Participate in Research

We are talking to parents with children in the Head Start program about Head Start health services. We want to find out how these services affect you and your child. Our goal is to describe the kinds of health services offered to families in the Head Start program and how they are used.

An interviewer will ask you questions about the health of your child and about the health services offered by your Head Start program. We want to know how your received health services. The interview will only take about 30 minutes. You may ask questions at any time during the interview. You may stop the interview at any time. Following the interview, we will review the information in your child's Head Start health file (you do not need to be present for this). You will not harm your relationship or your child's relationship with the Head Start program if you do not agree to the intervieand record review, or if you stop the interview.

We guarantee that we will protect your privacy. Your answers will not be shared with any other Head Start families or with staff from your Head Start program. No information will be given out that can identify you. Your name and an identification number be kept under lock and key. We will destroy any papers containing names and other identifying information as soon as they are no longer needed. Interviewers understand that your answers are sensitive and private. They will discuss answers without using your name, and only with others working on this study.

This project meets all the United States Department of Health and Human Services (DHHS) regulations for projects involving human subjects.

I have read the above description of this project (or it was read to me by _______________________________). Anything I did not understand was explained to me by _______________________________, and I had all of my questions answered to my satisfaction.

I agree to participate in this Project.
(Print): ____________________________________________________________
(Name of Parent)

(Signed): _______________________________________________________ ______________
(Name of Parent) Date

Signed): ________________________________________________________ ______________
(Name of Project Staff) Date

Thank you for agreeing to help us. If you have a copy of your child's immunization record, please bring it with you to the interview.