Survey

Appendix A1
Informed Consent Form

YouthBuild
Evaluation

Agreement to Participate in the YouthBuild Evaluation
You are invited to be part of the YouthBuild Evaluation. This form explains what it means to be in the study. To
join the study, sign your name at the end of the form. If you are younger than 18 years old, then your parent or
guardian will also need to sign the form.

What is the YouthBuild Evaluation?
Evaluation?
It is a study to learn how and whether the YouthBuild program helps the young people it serves. The study is
run by three organizations: MDRC, Mathematica Policy Research, and Social Policy Research Associates. The
U.S. Department of Labor and the Corporation for National and Community Service are sponsoring the study.

Who can be in the study?
Every volunteer who is eligible and appropriate for the YouthBuild program can be in the study.

What does it mean to be in the study?
You have a chance to get into the YouthBuild program. YouthBuild does not have enough funding to help
everyone who may want services. Therefore, young people will be selected
selected at random to get invited to mental
toughness/during
toughness/during mental toughness to continue in mental toughness/to
toughness/to get invited to the YouthBuild program
after mental toughness.
toughness. The selection is like a lottery; it has nothing to do with your age, race, gender or
anything else about you. If you do not get an invite, you will not be able to be in the YouthBuild program for 2
years. However, you will continue to be part of the study and you will be given a list of other services in the
community that may be helpful.
The study team will collect information on you for up to ten years.
•

Background information. Some information will come from your YouthBuild application.

•

Interviews. Some information will come from you. The study team will interview you up to three times.
You will receive a payment for each interview you do. You do not have to do the interview or answer any
questions that make you uncomfortable.

•

Program and government records.
records Other information will come from records about you. These records
may include information from YouthBuild and the U.S. Department of Labor about your program
activities. They may also include information at state and federal agencies about your employment and
earnings and information from the criminal justice system. In addition, the study team may collect
information about your education from the National Student Clearinghouse.

How will the study use your information?
The study team will use your information for research purposes only. The team will follow strict rules to protect
your privacy. Your information will be kept private and confidential. Your name will never be used in any report
written for the project.
project To help protect your privacy, the study has a Confidentiality Certificate from the U.S.
government. It says we do not have to identify you, even under a court order or subpoena. Please keep in mind:
This certificate does not mean the government approves or disapproves of the study. Also, the study team will
have to report your information if you tell us that you or someone else is in danger. The government may see
your information if it audits us, but it, too, will protect your privacy.

WHAT ARE THE BENEFITS
BENEFITS AND RISKS OF PARTICIPATING
PARTICIPATING IN THE STUDY
STUDY?
You will help YouthBuild and other programs learn how to provide better services for young people like you.
The risks are small. Even if you are not selected for the YouthBuild program, you will still be part of the study
and will have access to other services in your community. The study team will follow strict rules to keep your
data private.

Do I have to be in the study?
2 of 2

YB [INSERT SITE NAME] (07-19-11)

YouthBuild
Evaluation

Agreement to Participate in the YouthBuild Evaluation
No. The decision to be in the study is your choice. However, only people who are in the study will have a chance
to be in the YouthBuild program.
program You may drop out of the study at any time by contacting MDRC (see below). If
you drop out, the study team may use the information collected while you were in the study.

Statement
•

I have read this form and understand the information presented.

•

I agree to be in the YouthBuild Evaluation.

•

I know the decision to be in the study is my choice.

•

I know that I will have a chance to be in the YouthBuild program. If I am not selected, I will not be able to
be in the program for 2 years.

•

I understand I can drop out of the study at any time.

•

I know that the study team will follow strict rules to protect my privacy. My name will never appear in any
public document.

•

I understand that the study team will get information about me. The information will come from
programs and agencies, as described above.

•

I understand that my education records are protected under a federal law called the Family Educational
Rights and Privacy Act (FERPA). I further understand that I may waive that protection and give the study
team access to my records. I agree to waive my rights under FERPA; the study team can get education
records about me.

•

I understand that I may be contacted to take part in interviews. I know I do not have to answer any
questions that make me uncomfortable.

___________________________________________
APPLICANT DATE OF BIRTH (E.G. 01/01/1995)
___________________________________________
NAME OF APPLICANT (PLEASE PRINT)
___________________________________________
SIGNATURE OF APPLICANT
_______________________
DATE
____________________________________________
NAME OF PARENT/GUARDIAN IF UNDER 18 (PLEASE PRINT)
___________________________________________
SIGNATURE OF PARENT/GUARDIAN
_______________________
DATE
3 of 2

YB [INSERT SITE NAME] (07-19-11)

YouthBuil
Evaluatio

Agreement to Participate in the YouthBuild Evaluation
Questions about the YouthBuild Evaluation? Please contact [email protected] or call 1-866907-1936.

Federal Law called the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law
that protects the privacy of your education records. Generally, schools must have permission from you or your parent in order
to release your education records. When you sign this form, you will give permission to the study team to get your education
records.

DRAFT C:\Users\LWood\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\3EGNZSC9\Informed
Consent Form_12-Month-Survey.docx
4
09/12/12 12:49 PM