Client Consent Form

Appendix B

Client Consent Form

Homeownership Counseling Study

CONSENT TO PARTICIPATE

The U.S. Department of Housing and Urban Development (HUD) is conducting an important national study of the outcomes of homeownership counseling. The study is being conducted by a private research organization, Abt Associates, with the assistance of IMPAQ International. The study will involve approximately 2,000 individuals who seek homeownership counseling services from one of 30 housing counseling agencies across the country. The study will evaluate the effectiveness of different types of homeownership counseling through an initial questionnaire, tracking of counseling services received, and a follow-up telephone survey.

You have the opportunity to participate in the study because you are seeking pre-purchase homeownership counseling or mortgage delinquency or default counseling services from [AGENCY NAME]. Participation in this study is voluntary. If you choose to participate in the study, you will be expected to complete an initial 30-minute questionnaire today. The questions in this survey have been reviewed by the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (OMB control # xxxx-xxxx, expiration date x/xx/2009). If future funding becomes available, HUD expects to conduct a follow-up telephone interview with you as well. In that event, you would be asked to complete a 30-minute telephone survey. The questionnaire and follow-up interview will each ask about your housing situation, financial circumstances, employment, education, and your experiences with homeownership. You have the right to refuse to answer any of the questions in the interview.

In order to participate in the study, you will need to provide your social security number to allow [AGENCY NAME] to obtain a copy of your credit report and credit score today, approximately six months from now, and at the time of the follow-up telephone survey. You will receive a free copy of your credit report and credit score at each point in time. [AGENCY NAME] will also keep track of the homeownership counseling you receive over the next six months, including: the number of counseling sessions, the format of the counseling (group or individual), teaching methods used in the counseling, and action steps recommended by the counselor.

The information you provide will be kept confidential to the extent permitted by the Privacy Act of 1974 (5 U.S.C. 552a). The findings from the study will be publicly reported only at the aggregate level; neither individual clients nor participating housing counseling agencies will be identified in the study reports. The information you provide will only be used for research purposes and only the project staff at [AGENCY NAME] and research staff from Abt Associates and IMPAQ International will see your interview answers or your credit report information. You will never be named in the study.

CONSENT STATEMENT: By signing below, I am indicating that I have read and understand this form, and that I agree to participate in the homeownership counseling study. I agree to complete today’s initial questionnaire and to be contacted for a follow-up telephone interview at a later date. I also agree to allow [AGENCY NAME] to track the counseling services that I receive and to obtain my credit report at three points in time. I also understand that the information from the initial questionnaire, follow-up interview, and credit reports will be kept confidential, and that my name will not be used in the study.

PLEASE PRINT CLEARLY:

_____________________ ______________________ ________________________

First Name Middle Name Last Name

______-______-_________ ______________________

Social Security Number Date of Birth

___________________________ ______________________

Signature Date

If you have any questions about this study, please contact XXX of Abt Associates at 617-520-3062. If you have questions about your rights as a study participant, please contact Marianne Beauregard of Abt Associates at 617-349-2852. Please note that these are not toll-free telephone numbers. Please keep a copy of this form for your own records.

Future Contact Form

About a year from now, we will contact you again to see how things are going, as part of the study. To be able to contact you, we need your address and phone information.

ADDRESS:__ __

(NUMBER) (STREET) (APT. #)

(CITY) (STATE) (ZIP)

HOME PHONE #: WORK OR CELL PHONE #:

CELL PHONE #: EMAIL ADDRESS:

We would also like you to think of two relatives or friends who do not live with you but who would know how to reach you if you move in the next year. This could be your parents, the parents of your husband, wife, or partner, a brother or sister, an adult child, a favorite relative you keep in touch with, or a close friend. This information will be kept separate from your questionnaire answers. Who are two relatives, friends, or other people who will know where you are? Be assured that this contact information will be used to locate you only if we cannot find you using your own contact information above. The contact information you provide below will be kept secure and will not be used for any other purpose.

(1) NAME:

RELATIONSHIP TO YOU:

ADDRESS:

(NUMBER) (STREET) (APT. #)

(CITY) (STATE) (ZIP)

HOME PHONE #: _______________________

WORK OR CELL PHONE #:__________________________

(2) NAME:

RELATIONSHIP TO YOU:

ADDRESS:

(NUMBER) (STREET) (APT. #)

(CITY) (STATE) (ZIP)

HOME PHONE #: _______________________

WORK OR CELL PHONE #:__________________________