You are being asked to be in a research study about child care for children with special needs. We ask that you read this form and ask any questions that you may have before agreeing to be in this study.

Purpose of the Study
I understand that the purpose of this study is to find out about the experiences of parents in finding child care for their children with special needs. By listening to other parents I may learn about services I didn’t know about that might be available to my family. However, the main purpose of this study is to use the information from these discussions with parents to help bring about changes in programs so that families like mine can get more help.

Description of Study Procedures
If you agree to be in this study, we will ask you to fill out a registration form that asks questions about you and your family and to participate in a discussion group with other parents. This process will last about two hours. The discussion will be tape recorded and notes will be taken about what is said during the discussion.

Payments
I understand that I will receive $50 for participating in this focus group.

Voluntary Participation
I am voluntarily participating in this discussion. I know I may feel uncomfortable talking about some things about my family but I know I don’t have to say anything I don’t want to. I also understand that if I feel too uncomfortable to continue participating, I am free to leave the group at any time, without penalty or loss of the stipend.

Confidentiality
I understand that anything I say in this discussion, or any information I provide on the registration form, will be kept confidential. My name will not be shared with any person, agency or organization not connected with this project. Only first names will be used in the group discussion. Because this focus group is confidential, I agree to keep private anything anyone else says here today. All records and tapes will be kept in a locked file and will be destroyed at the end of the project. While there is always a risk of some people outside of the group hearing what is said in the discussion, I know that the research staff will do everything possible to keep all of the information I provide completely confidential.

Contacts and Questions
For more information concerning this research you may contact ………at…………..

Statement of Consent
I have read (or have had read to me) this form. I have had an opportunity to ask questions and have had my questions answered. I understand that I will receive a copy of this consent form. I give my consent to participate in this focus group.

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Print Name

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Signature

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