Consent to Participate Form

APPENDIX A
CONSENT TO PARTICIPATE FORM

FOR COUNSELOR USE ONLY:

Study ID #: |

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OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/20xx

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CONSENT TO PARTICIPATE
The U.S. Department of Labor is sponsoring a study of some of its employment and training programs that serve adults
and dislocated workers, to learn how well these programs are working and how they can be improved. The national study,
called the Workforce Investment Act (WIA) Adult and Dislocated Worker Programs Gold Standard Evaluation, is being
conducted by a team of researchers at Mathematica Policy Research, Social Policy Research Associates, and MDRC.
By signing this consent form, you are agreeing to take part in this very important study. As a participant in this study, the
following will happen:
A computer will assign you to one of three groups. Your placement in one of these groups is like a lottery—it will be
decided completely by chance and will not be affected by any of your characteristics. The group you are assigned to
will affect the services you can access for 15 months. The three groups are:
1. Full-WIA Group: If you are assigned to this group, you will have access to all of the WIA services normally
available to you. This may include access to WIA training funds to help pay for training at a state-approved provider, if
Center staff determine it is available and appropriate for you. Most people will be assigned to this group.
2. Core-and-Intensive Group: If you are assigned to this group, you will have access to all of the WIA services, if
available and appropriate, except WIA-funded training.
3. Core Group: If you are assigned to this group, you will have access to core services. Core services include
services in the resource room such as job listings and access to the Internet. You will not have access to WIA
services that require substantial staff time or to WIA-funded training.
The decision to participate in the study is up to you. If you decide not to participate, you will only have access to core
services. You may terminate your participation in the study at any time by writing to the WIA Evaluation, Mathematica
Policy Research, P.O. Box 2393, Princeton, New Jersey 08543-2393 or to Eileen Pederson, ETA - WIA Evaluation,
U.S. Department of Labor, 200 Constitution Avenue, NW, Washington, DC 20210. Any information we collect about
you prior to your termination request will be used for research purposes.
You may be contacted by an interviewer from Mathematica to complete two interviews by telephone over the next few
years. These interviews are voluntary, but they are very important to the success of the study. You will receive a
payment for each interview you complete.
Government agencies such as the Social Security Administration, Unemployment Insurance agencies, Employment
Service, and agencies that administer the Temporary Assistance for Needy Families (TANF), Supplemental Nutrition
Assistance Program (SNAP), and WIA programs may share information with the research team about your earnings
and government services and benefits you receive for up to 10 years.
All information that is collected about you through interviews or agency records will be used for research purposes
only. The information will be kept confidential in accordance with the Privacy Act of 1974 (5 USC 522a), Systems of
Record Notices DOL/ETA-15, unless the law requires otherwise, or you request release of your information in writing.
Your name will never be used in any reports and no information will be reported in any way that can identify you.
I have read this consent form (or it has been read to me). I understand the information provided in these
materials and voluntarily agree to participate. If I have questions I can call the study toll-free number at 1-800925-0356.
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CUSTOMER’S NAME (Printed)

SOCIAL SECURITY NUMBER—LAST 4 DIGITS ONLY

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CUSTOMER’S SIGNATURE

DATE

Public Burden Statement
Completing this document, which seeks to help the U.S. Department of Labor understand the effects of WIA-funded services on customers’ employment-related outcomes, is
voluntary. The public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate
to the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

WIA Study Consent Form Appendix A (Consent Form) September 20 2011.docx