Client Consent Form

Appendix B

Client Consent Form

DHAP Incremental Rent Transition (IRT) Study

CONSENT TO PARTICIPATE

The U.S. Department of Housing and Urban Development (HUD) is beginning an important national study of the Disaster Housing Assistance Program (DHAP). The goal of this study is to understand what happens to you and other DHAP participants after DHAP assistance ends. The study is being conducted by HUD’s Office of Policy Development and Research.

In order for HUD to conduct this important study, HUD needs your permission, or consent, to be able to contact you and track specific things that occur to you as a study participant after DHAP ends. HUD would like you to agree to participate in the study so that we may have contact information for you and the ability to get in touch with you in the future (probably 6, 12, 18, or 24 months after DHAP ends). The study will involve approximately 3,000 DHAP families. The study will evaluate the effectiveness of DHAP in transitioning people from rental assistance to market rate housing after Hurricanes Katrina and Rita through an initial questionnaire, tracking of housing locations through the National Change of Address (NCOA) database, and a follow-up telephone survey.

You have the opportunity to participate in the study because you are receiving housing assistance through the Disaster Housing Assistance Program (DHAP). Participation in this study is voluntary. If you choose to participate in the study, you will be expected to complete an initial 15-minute questionnaire today, for which HUD expects to provide you with a $15 gift card for completing the questionnaire. The questions in this questionnaire 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).

HUD expects to conduct follow-up checks on the National Change of Address (NCOA) database every six months and a follow-up telephone interview with you in the future, about 12 to 24 months after DHAP ends. If you agree to participate, this follow-up telephone interview will take about 30-minute to complete. HUD expects to provide you with a $20 gift card for completing the telephone survey. The questionnaire and follow-up interview will each ask about your housing situation, financial circumstances, employment, education, and your experiences with DHAP rental assistance and market rate housing. You have the right to refuse to answer any of the questions.

In order to participate in the study, you will need to provide your full name and address, your phone number, and your social security number to allow HUD or the private research firm that will be awarded the contract to conduct the study, to update our address records with information from the NCOA every six months during the study follow-up period and at the time of the follow-up telephone survey (12 to 24 months from now). As an additional benefit you will receive a free copy of your consolidated credit report (from the three credit reporting agencies, Equifax, Experian, and Trans Union) and credit score from a “soft hit” or “soft inquiry” on your credit report at the time the telephone survey is conducted. (A “soft hit” or “soft inquiry” means that when a HUD contractor will check your consolidated credit report and your credit score, there is no affect on your credit score.) HUD will keep track of your address and any address changes reported in NCOA in order to be able to locate you to conduct the telephone survey 12 to 24 months from the end of DHAP. Should you become a HUD-assisted household, HUD will use the Public and Indian Clearinghouse (PIC) database to keep track of any address, household, income, assistance, or employment changes.

HUD does promise confidentiality as stated in the Privacy Act of 1974 (5 U.S.C. 552a), Records Maintained on Individuals. The findings from the study will be publicly reported only as a group; your name and individual responses will not be identified in the study reports. The information you provide will only be used for research purposes and only the project staff from HUD’s Office of Policy Development and Research and research staff from the HUD selected contractor will see your NCOA or PIC data (if applicable). Only project staff from HUD’s Office of Policy Development and Research and research staff from the HUD selected contractor will see your consent forms and your responses to the baseline questionnaire. Only research staff from the HUD selected contractor will see your telephone survey responses. 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 DHAP Incremental Rent 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 the HUD selected contractor to track any address changes in my home address in the NCOA, in PIC if I begin receiving housing assistance through a PHA or HUD, and to obtain my credit report at the time of the telephone follow-up survey. I also understand that the information from the initial questionnaire, follow-up interview, and NCOA database 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 or about your rights as a study participant, please contact Marina L. Myhre, Ph.D., Social Science Analyst, Program Evaluation Division, Office of Policy Development and Research, U.S. Department of Housing and Urban Development at (202) 402-5705. Please note that this is not a toll-free telephone number. Please keep a copy of this form for your own records.

DHAP IRT Study Confidential ID Number : ___________________

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 #:__________________________

EMAIL ADDRESS: ______________________@_________________

(2) NAME:

RELATIONSHIP TO YOU:

ADDRESS:

(NUMBER) (STREET) (APT. #)

(CITY) (STATE) (ZIP)

HOME PHONE #: _______________________

WORK OR CELL PHONE #:__________________________

EMAIL ADDRESS: _______________________@_________________