Adult Program Pilot

OMB Control #1505-XXXX

Research Participant Information and Consent Form

We invite you to participate in a study led by the NYC Office of Financial Empowerment and the University of Wisconsin Center for Financial Security. This form explains what it means for you to be in the study. By signing this form, you are agreeing to be in the study and to let us use different types of information, described below, that we need to collect for the study. We hope you will agree to participate.

Your participation is voluntary. If you decline, it will not affect any services you receive at the Parks Opportunity Program (POP). If you agree, we will ask you to fill out a 20-minute survey now and 5 months later. You will receive a $25 gift card if you agree to participate and an additional $25 gift card if you have a NYC checking account or open one now.

If you agree, we will use information from: (1) your POP employment, (2) financial counseling services you may receive through a referral from POP, and (3) your credit report. Your credit report will be pulled now and up to three points in the future. The pulling of these credit reports will not affect your credit in any respect. If you agree to participate in the study, we will also ask you to sign a form releasing data about your NYC checking account if you have one or choose to open one in the future.

We will only use this information to see if services provided by POP help people improve their financial situation. There is little risk to you because we will NOT use your name or any information that identifies you in the study. You may stop participating in the study at any time, and this will not affect your participation in POP.

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I agree to participate in the study to help the Office of Financial Empowerment and the Center for Financial Security learn more about how to develop better programs that can help me and others in my community.

Print Name: ____________________________________________

Signature: ______________________________________________ Date: ______________________

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WHO DO I CONTACT IF I HAVE QUESTIONS?

You may ask questions about the research at any time. You can contact Davida Rowley at the Parks Opportunity Program. She can be reached at 212-830-7783.

If you have questions about the survey you should contact Nicole Truog who works for the Center for Financial Security. She can be reached at 608-262-6766.

If you have more questions, you should contact the University of Wisconsin IRB Office. The number for the office is 608-263-2320. The office staff can talk to you about your rights as a research participant.