If yes, please list the person’s:
ONLY if you are between the ages of 14 and 25 (answered “yes” to above), have you experienced any of the following?
if you are currently a parent or caring for a child (answered “yes” to above) please also complete the next section.
If you do not currently have any children, you do not need to complete this section
The following information is collected as part of the CR/CYI EVALUATION
The following items as applicable
The following information will be shared with other provider partners in the community for SERVICE PROVISION
Participant Information Form that may help other agencies provide you services
SHARE MY INFORMATION FOR EVALUATION.
I hereby grant permission for the local Community Well Being coordinator and/or necessary staff and the (CR/CYI Agency or agencies) to share my information with Nebraska Children and their contracted evaluators including Munroe‐Meyer Institute, as part of the EVALUATION of this program that is funded in part by Nebraska Children. You are participating in a Community Response that is sponsored by CWCC which is a federally funded grant. This is to inform you that we will be asking you to complete surveys are part of the evaluation, which is being completed by Munroe‐Meyer Institute at the University of Nebraska Medical Center. Information from this evaluation may help the program better support families in similar programs. Your name will not be included in any of the information that you provide us. All data collected will only be summarized as a group. No individual responses will be reported. If you have any questions about this research project, please call Dr. Barbara Jackson at 402‐559‐5765. You are not required to share this information. If you decide not to have this information shared, it will not affect you or your standing in our program in any way. For evaluation reporting purposes, your information will always be combined and will not be identifiable at the individual family level.
SHARE MY INFORMATION FOR SERVICE PROVISION.
I hereby grant permission for the local Community Well Being coordinator and/or necessary staff and the CR/CYI Agency or agencies to share my information with other partnering agencies to assist in PROVIDING ME OR MY FAMILY WITH SERVICES. I understand that if I do not mark this box, I will be responsible for reaching out to other partner organizations for further assistance on my own time.
If you have questions about the evaluation, please contact Barbara Jackson at Munroe‐Meyer Institute at 402‐559‐5765 or Catherine Brown at Nebraska Children and Families Foundation at 402‐302‐1588.
If you are a minor, you must fill out the PDF Referral Form and submit to Brittney Livingston.