Attachment 1 - HHMI - Individual-Small Groups Consent Form

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CONSENT TO PARTICIPATE IN INDIVIDUAL/SMALL GROUP INTERVIEW: HISPANIC HEALTHY MARRIAGE INITIATIVE GRANTEE IMPLEMENTATION EVALUATION

What is the Hispanic Healthy Marriage Initiative Grantee Implementation Evaluation Study?

Hispanic families and youth are a growing part of the target service population for a range of social service programs, including those aimed at strengthening families. The federally funded Hispanic Healthy Marriage Initiative (HHMI) seeks to identify the unique cultural, linguistic, demographic, and other factors that need to be considered in designing and delivering family strengthening services to Hispanics.

The HHMI Grantee Implementation Evaluation will document and explore lessons about diverse programmatic approaches to improve Hispanic family well-being through healthy marriage education programs. The evaluation will obtain information from approximately nine grantees across the country about the ways in which they are developing, adapting, and implementing culturally relevant and appropriate healthy marriage programs for Hispanic populations. The evaluation will also explore the extent to which grantees are working with partners in the community to provide a range of supportive services to their participants. The U.S. Department of Health and Human Services sponsors the study. The Lewin Group, a national research and evaluation company is conducting the study.

What is an Individual or Small Group Interview?

The evaluation team is visiting various programs delivering healthy marriage curriculum to talk with individuals who help to implement and/or operate the HHMI program. Interviews will be one-on-one or in small groups. The evaluation team wants to learn about your work with the HHMI program. We will ask you about topics such as the structure of the program and whether it has changed over time, the program participants, your role in the program, and your impressions of the program. These discussions are expected to last approximately 90 minutes.

Your Answers will be kept Private.

Everything you tell us will be kept private. What you share will not be shared with other program staff, including your supervisor. Only the evaluation team will have access to the information you provide. Your name will not be listed in any reports published and comments will not be attributed to you. Instead, your information will be combined with information provided by others. In rare cases, information may be released, if required by a court of law. For example, if a person says that he or she is abusing a child and the state has laws requiring that child abuse be reported, we will comply with the law.

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Your Participation is Voluntary

You should participate only if you want. You may choose not to take part; there will be no penalty.

Risk of Taking Part in the Study

There are no known risks to you if you take part in this study. If any questions make you uncomfortable, you should not answer them.

Signing this form means you have read both pages of this form.

• You agree to participate in this interview being conducted by the HHMI evaluation team.

• Everything you share will be kept private. Only the research team will be able to look at what you share, and it will be used only for the study. Information will only be released if required by law.

If you have questions or concerns about your rights as a participant in this study, you may contact the study director at The Lewin Group, Karen Gardiner ([email protected]), for any questions you may have about the study.

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Name of Participant (Print)

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Signature of Participant

Date __________________________________

REMINDER: Ask each participant to sign two copies of the consent form. One is for them to keep and one is to be kept for program files.

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Name of Person Obtaining Consent (Print)

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Signature of Person Obtaining Consent

Date __________________________________