Infomed Consent Template

OMB Control Number:

THE URBAN INSTITUTE

VETERANS HOMELESSNESS PREVENTION DEMONSTRATION (VHPD)

Informed Consent – August 2012

Introduction/Purpose

[GRANTEE/SUBGRANTEE] is participating in a national study to understand what happens to veterans who receive help with rent and other assistance to help them keep their housing or get back into housing quickly. The study is funded by the U. S. Department of Housing and Urban Development (HUD). We’d like to interview you by telephone very soon, as you begin working with [GRANTEE/SUBGRANTEE], and again about six months after your rental assistance ends. Each interview will last about 25 to 30 minutes. The information being collected from veterans like yourself will show federal, state, and community level policy makers how housing assistance may help veterans get back into housing and stay there. This is a chance to get your voice heard, since HUD will use this information to help improve the VHPD program and other homeless prevention programs like it. Your participation in these interviews is voluntary. This agency may not collect this information, and you are not required to complete these interviews unless they display a currently valid OMB control number.

Benefits of Participating in the Study

We want to know from people like you, who have used programs like [GRANTEE/SUBGRANTEE]’s VHPD program, about your experiences with these agencies. Your participation in the study is very important, because you can contribute information from first-hand experience that may help to improve programs for veterans and their families throughout the country. Without this information, no one can be sure if the services help families like yours and how the programs can be improved. Also, the VHPD program is currently only a temporary program, and information on how the program works will help Congress make decisions on future programming for preventing homelessness among veterans.

Possible Risks to You of Participating

You should know that we will ask you to talk about your recent housing situation, including the possibility or reality of losing your housing. This may remind you of negative feelings or may trouble you in other ways. If this happens, you should know that the interviewer will be able to refer you to resources in the community to help you if you need it. Should you need assistance, you can contact[LOCAL RESOURCE].

Who Is Conducting this Study?

Silber & Associates and its partner, the Urban Institute, are conducting this study. The Principal Investigator is Bohne Silber of Silber & Associates. If you are willing to be part of the study, an interviewer from Silber & Associates will call you for an interview within the month. A trained staff person will interview you, and will keep all of your answers completely confidential.

What Will I Be Asked About?

You will be asked about:

• Your experiences at [GRANTEE/SUBGRANTEE] and your opinions of the agency and its staff—what helped you and your family the most, what would have helped;

• Your experiences of threatened loss of your housing, or of homelessness;

• Whether you live by yourself and, if not, who lives with you;

• Things about you and your family that make it easier or harder for you to find and keep housing;

• If you have children, how are they doing, in school and generally;

• Some background information about you and your family; and

• What kinds of services would be helpful for people in similar situations.

What Other Information Will the Researchers Collect?

If you agree to participate, the research staff will collect information that you gave to [GRANTEE/SUBGRANTEE] when you applied for its veterans program, and that [GRANTEE/SUBGRANTEE] stores in the computer databases that the [SITE] area uses to keep track of people using any homeless service. The research team will not collect your social security number. The research staff will also check these same databases after you stop receiving assistance through [GRANTEE/SUBGRANTEE]’s VHPD Program to see whether you may have used any other services for people facing homelessness. Also, as part of trying to keep in touch with you, if the interviewer loses touch she may try to find you by contacting people at [GRANTEE/SUBGRANTEE]. The research staff will also collect information regarding the dates of your program entry, exit and any moves that occur while you are enrolled in VHPD as well as your housing situation at each of those times (e.g. living in your own place, living in someone else’s place, etc.).

Procedure

If you agree to participate, [GRANTEE/SUBGRANTEE] will give Silber & Associates your contact information, and a Silber & Associates staff person will contact you to schedule a telephone interview. That person will call you again for a follow-up interview six months after you stop receiving assistance through [GRANTEE/SUBGRANTEE]’s VHPD Program. They will not leave messages for you if you ask them not to, and will follow your instructions for how to reach you safely by telephone. They will use your instructions to try to contact you up to seven times if they do not reach you at once. Each interview should each take about 30 minutes of your time to complete.

Voluntary Participation

You should understand that your participation is voluntary and will have no effect on the services you receive from [GRANTEE/SUBGRANTEE] or any other service agency. You should also understand that your decision about participating does not affect [GRANTEE/SUBGRANTEE] or the money it receives to provide services. You may also refuse to answer any question at any time during the interviews themselves.

Confidentiality

The information you provide will be kept confidential and only used for this study to the extent allowed by the Privacy Act of 1974. You should understand that no researcher or interviewer will reveal the fact that you are participating in this study—no one will know unless you tell them yourself. Your name will not appear on the interviews and will not be identified in any reports of the study. No researcher or interviewer will ever tell anyone how you answered the questions, or even that you participated in the study. You should also understand that all of your answers will be stored in databases with secured password protection and accessed only by research staff who have signed pledges, to ensure your privacy. Your answers and other data will not be shared with [GRANTEE/SUBGRANTEEGrantee or Subgrantee], the VA, or any other local agency responsible for the VHPD program. However, if you tell the interviewer about child or elder abuse/neglect or if you are suspected of being an immediate danger or harm to yourself or others, in accordance with applicable state laws, he or she is required to report it.

Compensation

You will receive $30.00 for each interview – a total of $60.00 if you participate in both interviews. These funds are offered as a token of appreciation for your participation.

Contact Information

You should understand that you will be asked to provide the study with safe ways to contact you by telephone, either at your home or through trusted friends and relatives who will know where and how to reach you. You should know that Silber & Associates will receive this contact information, and will use it only to contact you for the interviews. Once the project is completed, all information that could let someone contact you or connect you to any of your answers will be destroyed.

Questions

If you have any questions about the study, you can contact [URBAN INSTITUTE SITE LIAISON] at 202-261-[XXXX] or Silber & Associates at 1-888-745-2371.

Written Consents – Participation in telephone interviews and focus groups

My rights as a study participant have been explained to me and my signature/initials below indicate that I understand my rights. I am willing to participate in this study of how housing programs help veterans. I understand that by agreeing to participate in this study I grant the research team of Silber & Associates and the Urban Institute the following permissions:

• Permission to use the contact information I provide only for the purposes of reaching me for an interview and/or focus group, after which it will be destroyed;

• Permission to collect information on my housing situation throughout my participation with VHPD from [GRANTEE/SUBGRANTEE];

• Permission to access and use all the information, except my social security number, that I gave to [GRANTEE/SUBGRANTEE] when I applied for its veterans program that is stored in client files and was entered into the local homeless management information system (HMIS) in [LEAD VHPD COC], which is a computer database that keeps track of people using any homeless service;

• Permission to access and use all my information, except my social security number, contained in the surrounding communities’ homeless management information systems (HMIS) where information may also have been entered if I received services in those communities;

• Permission to contact [GRANTEE/SUBGRANTEE] to search my community’s homeless programs database to find me, in case the interviewer and I lose touch between interviews.

I understand that the research team of Silber & Associates and the Urban Institute will only use this information for research purposes, and will maintain confidentiality as dictated by the Privacy Act of 1974. I have been given a copy of this form to keep.

Signature: ________________________________ Date: _________________________

Printed Name: _____________________________

Witness: _______________________________ Site: ___________________

Contacts Who Will Always Know How to Find Me

Can we please have the telephone numbers and addresses of three people who will always know where to find you and do not live with you? This information will only be used to help the interviewer get in touch with you. First please give me your own contact information. Then give me information of the person who is most likely to know where you are and that you are comfortable with us contacting (for example, a friend or relative). Also give me two more contacts who are very likely to know where you are. Any of these contacts could be someone in the [SITE] area that you are close to. If you are using an alias, please let the other contacts you provide know that you have done so.

Your Own Contact Information: Rank Order:

Name: ____________________________________

Telephone Number: ____________________________________

Other number (e.g., cellphone): ____________________________________

Address: __________________________________________________________

When are the best times to contact you (time of day, day of the week, etc.)?

__________________________________________________________________

Comments: (any safety precautions she would like to add—e.g., don’t leave a message, use a different name, etc.)

___________________________________________

O ther Contact #1: Rank Order:

Name: ____________________________________

Relationship: ____________________________________

Telephone Number (Home): ____________________________________

Telephone Number (Cell): ____________________________________

Address: ____________________________________________________

Email Address: ____________________________________

When are the best times to contact this person (time of day, day of the week, etc.)?

_______________________________________________________________________

O ther Contact #2: Rank Order:

Name: ____________________________________

Relationship: ____________________________________

Telephone Number (Home): ____________________________________

Telephone Number (Cell): ____________________________________

Address: ____________________________________________________

Email Address: ____________________________________

When are the best times to contact this person (time of day, day of the week, etc.)?

_______________________________________________________________________

O ther Contact #3: Rank Order:

Name: ____________________________________

Relationship: ____________________________________

Telephone Number (Home): ____________________________________

Telephone Number (Cell): ____________________________________

Address: ____________________________________________________

Email Address: ____________________________________

When are the best times to contact this person (time of day, day of the week, etc.)?

_______________________________________________________________________