Appendix_B_Informed Consent 10-10-12

Appendix B

Informed Consent Form

Appendix B

Informed Consent Form

Updated 10.10.12

STED Informed Consent Form

You are invited to take part in a research study called the Subsidized and Transitional Employment Demonstration (STED). The goal of STED is to test employment programs for people with a variety of barriers to regular employment. STED is funded by the U.S. Department of Health and Human Services (HHS) and is being conducted by MDRC and its research partners: MEF Associates, Branch Associates, and D.I.R. Inc.

What is the STED program?

STED programs provide temporary employment subsidies and other kinds of support. Their goal is to help people with a variety of barriers to employment in the regular labor market find and hold jobs.

Who is eligible to be in the STED program?

Depending on the program you are interested in, you will be eligible to be in the STED program if you fall into any of these groups:

• Low-Income: Anyone whose income falls below 200% of the federal poverty level or who is currently receiving TANF benefits. For example, a family or household of four would have to earn a combined annual income of less than $47,000 in order to be eligible for the program.

• [Additional eligibility criteria will be determined based on the programs selected for the evaluation.].

There are not enough funds to enroll everyone into the program. Everyone who is eligible and interested in the program will be given an equal chance of being assigned to one of two groups:

1. Program group. If you are assigned to the program group, you will be able to enroll in the program and interview for a temporary job.

2. Control group. If you are assigned to the control group, you will not be able to enroll in the STED program, although you may enroll in other similar programs and services in your community.

A process called random assignment will be used to decide who gets assigned to one of these two groups. Random assignment is like a lottery. It has nothing to do with your age, race, gender or other personal traits.

What does it mean to be a part of this study?

If you agree to be in the study by signing this form, the research team will collect three types of information about you:

1. Background information. You will be asked to provide information about yourself such as your age, race, gender, social security number, employment, and education.

2. Contact data. In the future, the research team may contact you to complete an interview or survey about your work experience, relationships with your children, and/or experience with the program. To help contact you, you will be asked to list the names of people who know how to reach you.

3. Other information. By signing this form, you give the research team permission to collect additional information:

• The Department of Health and Human Services will provide the research team with information about your participation in the STED program if you are assigned to the program group.

• Researchers will collect information from state and federal agencies about things like your earnings and TANF receipt or other public benefits. The research team will use your social security number to get this information.

• Researchers may collect information from agencies in the community about your participation in other programs.

How will my information be kept private?

The research team will follow strict rules to protect your privacy. All research staff working on this project are trained to protect private information, and have signed a pledge to keep your information private to the extent permitted by law.  Any papers that include your name or other ID’s will be kept in a locked area, and any computer files with your name will be protected by a password. This applies to case file reviews and administrative records. Your name will never be used in any report written for the project. However, please keep in mind that MDRC will have to report to the authorities if you tell a member of the research team that you want to harm yourself or someone else. Also, MDRC may have to give up information about you if ordered to do so by law. 

What are the benefits and risks of participating in the study?

By participating in the study, you will help policymakers and other programs around the country learn how to create better employment programs for people in a similar situation as you. You can refuse to answer any question that you do not want to answer. There is a possible risk of loss of privacy. However, the research team has protections in place to securely store the data and minimize this risk.

You are not required to take part in the study.

If you decide not to be in the study, there is no penalty. Your decision will not affect your receipt of any public benefits, including TANF. However, only people who are in the study will have a chance to be in this program. If you agree to participate and then change your mind, you may drop out of the study at any time by contacting the person listed below. If you choose to drop out, the research team may still use information that was collected about you while you were in the study.

When does my participation begin?

This agreement is effective from the date you sign it (below) for 10 years.

What does signing this form mean? It means you agree to the following statement:

“I have read this form and agree to be in the Subsidized and Transitional Employment Demonstration (STED) study. I know that my participation is voluntary, that all information about me will be kept private to the extent permitted by law, and that my name will never appear in any public document. I know that I can withdraw from the study at any time without penalty. I understand that the research team will get information about me from programs and agencies, as described above.”

__________________________________________________________________________________________

Your Name (Print) Your Signature Date

If you have questions about the program, please speak with a staff person. If you have questions about the study, please contact Vanessa Martin at 212-340-8696 or [email protected], or by mail at:

MDRC

16 East 34^th Street, 19^th floor

NY, NY 10016

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