Alternative Housing Pilot Program Evaluation Baseline Survey

Annex A - Application for Alternative Housing Pilot Program

Supplementary Questionnaire - January 16, 2008

Mississippi Emergency Management Agency

Mississippi Alternative Housing Program

PARTICIPANT DEMONSTRATION ENROLLMENT FORM

The Mississippi Emergency Management Agency (MEMA) has special housing available through the Mississippi Alternative Housing Program (MAHP) for people who were displaced by Hurricane’s Katrina or Rita who are currently living in, or eligible to live in, a FEMA trailer. These special housing units have been made available through funding from FEMA.

FEMA has asked the US. Department of Housing and Urban Development (HUD) and its contractor

Abt Associates Inc., a research company in based in Bethesda, MD to help them keep in touch with people who apply for these special housing units. As part of this process, the enclosed survey asks questions about you and the people who live with you. You may be contacted by researchers from Abt Associates, Inc. and asked to fill out other surveys or be interviewed from time to time over the next 4 years.

This study will follow strict rules to protect your confidentiality. The information on these surveys will be kept confidential to the extent permitted under the Privacy Act. Your information will be used for research purposes only. We are conducting surveys with about 5,000 people across five sites. Only results from groups of people will be reported. Abt Associates will use this information to let HUD and FEMA know how families that receive these special housing units are doing.

Your participation is voluntary. You can refuse to answer any questions if you like. You may stop the survey at any time or skip specific questions. You will not lose any benefits if you decide not to participate, skip specific questions, or stop the interview. At this time, we would like to ask you to agree to participate in this study. Please review the statements on the next page. If you agree with the statements and are willing to cooperate in this study, please check the “Yes” box and then sign and date the form.

If you get a unit through the Mississippi Alternative Housing Program (MAHP), you may be asked to come to meetings to talk about your housing and neighborhood, and changes you and your family have experienced over time. Even if you agree to participate in the study, you can decide not to participate in the future surveys without penalty. However, your experiences are important to the study.

Abt

Institutional Review Board

Approval Date: 10/29/07

Expiration Date: 10/28/08

) acknowledge that by signing

this form, I understand the following statements:

• People who apply for this housing may become part of a research study. The research study is being done by Abt Associates, Inc. and the Department of Housing and Urban Development for FEMA.

• This housing and this research study are open only to those families who were displaced by Hurricanes Katrina or Rita.

• Participation in this research study may include completing surveys periodically during the next four years. These surveys will ask questions about my housing, employment, family, and health.

• My participation in this study is voluntary and I can quit at any time.

• When doing these surveys, I can choose not to answer any questions I am uncomfortable with.

• Approximately 5000 people applying for alternative housing program will be asked to answer these questions.

• In no way does my participation in this survey affect any other forms of housing assistance I may or may not receive now, and

• My responses will be used for research purposes only.

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Signature

Date

FEMA #

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Name: Please Print

Abt ID:

Case ID:

□ YES, I have read this form and I am willing to participate in the study. I agree to let the researchers studying this program contact me about participating in future surveys or interviews and get information about me or my children from FEMA, HUD, or other government agencies. Your individual responses will be maintained securely and only be seen by the researchers working on this project.

□ NO, I have read this form and have decided not to participate in this study.

I (PRINT NAME:

• All of my responses will be kept private, and no one will be able to see my name and answers together.