0990-CHIP Part A_Attachment I3_Focus Group Consent Form for Parents of Eligible but Uninsured

ATTACHMENT I3
FOCUS GROUP CONSENT FORM FOR PARENTS OF ELIGIBLE BUT UNINSURED

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Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

FOCUS GROUPS: PARTICIPANT INFORMED CONSENT
Study Title: Children’s Health Insurance Program Evaluation
Principal Investigators: Ian Hill, MSW, MPA, Sheila Hoag, MA
Sponsor’s Name: U.S. Department of Health and Human Services
Introduction/Purpose
You are invited to participate in the Department of Health and Human Services (DHHS) evaluation
of the Children’s Health Insurance Program, or the [state CHIP program name]. This study is funded
by the U.S. Department of Health and Human Services. Results from this evaluation are intended to
inform policymakers how this program is working for children and families like yours. You were
selected as a possible participant in this study because your child is currently uninsured but may be
eligible for [state CHIP program name]. Before you decide to be a part of this study, you need to
understand the risks and benefits associated with your participation.
Procedure
You will be asked to participate in a focus group discussion. A colleague and I will be taking written
notes of your answers. The focus group will be audio recorded with your permission. There will be
no representatives from the [state CHIP program name] present at the focus group. If you do not agree
to have the focus group recorded, please let me know.
There are no “right” or “wrong” answers; we are only interested in learning about your experiences
and opinions. You may choose to not answer any and all questions that I ask, and you may leave the
focus group discussion at any time as well. The focus group discussion will last between 1.5 and
2 hours.
Benefits
Participating in this focus group discussion may not benefit you personally. You will be asked about
your experiences, if any, with the [state CHIP program name] program, and about your experiences
having a child or other family member who is uninsured. While you will not benefit directly from
this study, your comments will help inform policymakers and providers about how well the [state
CHIP program name] is serving children.
Risks
There is no known risk to you for participating in the focus group. Although we have made every
effort to reduce any risk to you by participating in this focus group, and to make sure everything is
confidential, you may decide not to answer any questions that make you feel uncomfortable in any
way.
Compensation
For your participation, you will receive $50 in cash; light food and refreshments will also be served.

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Confidentiality
To protect your privacy, all of the information that you provide us will be kept confidential. You will
not be personally identified in any report or publication of this study. Recordings from each focus
group will be stored in a project password protected folder that can only be accessed by the study's
research team. The focus group notes/summaries will be locked in a file folder in a locked project
office. Records can be opened by court order or produced in response to a subpoena or a request
for production of documents. We will keep any records that we produce private to the extent we are
required to do so by law. The records will be destroyed after the completion of the project by
deleting them from the password protected project folder on the evaluation team’s research
network. All documents created from the focus group will be shredded after the end of the project.
Participation is Voluntary
If you agree to participate in this study, please understand that your participation is voluntary. You
have the right to withdraw your consent or stop your participation at any time without penalty. You
also have the right to refuse to answer any questions during the focus group.
Questions
If you have any questions about this focus group, including any questions that concern your rights as
a participant on the project, you can contact Sheila Hoag at (609) 275-2252. Mathematica uses
Public/Private Ventures (P/PV) in Philadelphia, PA, as their Institutional Review Board. You also
may call Margo Campbell at P/PV at (215) 557-4446 if you have questions about your rights as a
participant in this study. This Review Board oversees the protection of human research participants.
Agreement Statement
Do you agree to participate in the Mathematica Policy Research/Urban Institute Evaluation of the
Children’s Health Insurance Program?
Yes ____ No ____
Do you agree to have this focus group recorded?
Yes ____ No ____
Date of Consent: ___________________
Name of Focus Group Moderator (print): __________________________________________
Signature of Focus Group Participant: _____________________________________________
Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0990- . The time required to complete this information collection is estimated to average two hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,
Attention: PRA Reports
Clearance Officer.

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