3170-XXXX Consent for Participation in Research

Consent for Participation in Research
Evaluation of [The Financial Clinic/SFLUM]
Introduction/Purpose
[The Financial Clinic/SFLUM] is participating in a national study to understand how
financial coaching programs such as the one provided by this organization can help improve the
financial outcomes for coaching participants. The study is funded by the Consumer Financial
Protection Bureau, the federal agency established in 2010 to protect consumers’ interests. We
would like to have you complete our application form today, and we would like to interview you
by telephone in early 2014.
We want to assure you that the information that we collect in the application form and in the
later outcomes survey will be kept private. This information will be combined with information
from all other study participants and will not be reported or shared in a way that would allow
anyone to link what you tell us with who you are. We will not publish your name or other
personal identifying information in anything we write or talk about. We also will not share
information that identifies you, including your name or information from your credit report, with
anyone outside of the research team, including the Consumer Financial Protection Bureau. All of
your answers will be stored in databases with secured password protection and accessed only by
research staff who are committed to ensuring your privacy, and who have signed data privacy
pledges. Your participation in this study is voluntary.
Benefits of Participating in the Study
We want to know from people like you, who are seeking out financial coaching programs
like [The Financial Clinic/SFLUM]’s coaching program, what your relationship with your
finances is like. Your participation in the study is incredibly important because you can
contribute information from first-hand experience that can help to improve programs for others
in financial distress throughout the country. The report that results from this study will help
researchers and policymakers understand how these programs can better serve individuals like
you and communities like yours. Again, please remember that the information you provide will
be combined with information from all other study participants and will not be reported or shared
in a way that would allow anyone to link what you tell us with who you are. Without the
information we gather through this study, no one can be sure if the services help individuals like
you or how current programs can be improved.
Possible Risks to You of Participating
You should know that we will ask you to talk about your personal financial situation, as well
as circumstances that may have contributed to your desire to seek out financial coaching. This
may remind you of difficult situations or cause negative feelings. 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 would like it.
Who Is Conducting this Study?

The Urban Institute, a research organization based in Washington, D.C., [The Financial
Clinic/SFLUM], and [Survey Organization] are conducting this study. The principal investigator
is Dr. Margaret Simms of the Urban Institute. If you are willing to be part of the study, you will
complete an application administered by your financial coach, and an interviewer from [Survey
Organization] will call you for an interview in early 2014 for a final telephone survey.
What Will I Be Asked About?
You will be asked about your:
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Family members, including your education level and employment status;
Income, including any public benefits ;
Expenses, bills, as well as how you pay your bills;
Kinds of bank accounts you have, and other alternative financial providers you may rely
on for services;
Financial goals you have, and plans and progress you made towards achieving them; and
Kinds of financial stress that you may experience.

Contact Information
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.
[Survey Organization] will receive this contact information, and will use it only to contact you
for the interviews.
What Other Information Will the Researchers Collect?
If you agree to participate, the research staff will collect information that you give to [The
Financial Clinic/SFLUM] when you apply for its financial coaching program, and that [The
Financial Clinic/SFLUM] stores in its computer databases. We will also ask for your social
security or tax identification number so that we can retrieve your credit report as a part of the
research study. If the interviewer loses touch with you while we are conducting the outcomes
survey, he or she may try and find you by reaching out to the contact individuals you list on the
application form, or the employees at [The Financial Clinic/SFLUM].
Procedure
If you agree to participate, a [The Financial Clinic/SFLUM] financial coach will ask you to
fill out a study application form and will give [Survey Organization] your contact information. In
late 2013, a [Survey Organization] staff member will contact you to schedule a telephone
interview for the final telephone survey. 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. Each
interview should each take about 40 minutes of your time to complete.
Privacy
You should understand that no researcher, financial coach, or interviewer will reveal the fact
that you are participating in this study—no one will know unless you tell them yourself. The
information that we collect in the application form and in the later outcomes survey will be kept

private. This information will be combined with information from all other study participants and
will not be reported or shared in a way that would allow anyone to link what you tell us with who
you are. We will not publish your name or other personal identifying information in anything we
write or talk about. We also will not share information that identifies you, including your name
or information from your credit report, with anyone outside of the research team, including the
Consumer Financial Protection Bureau. All of your answers will be stored in databases with
secured password protection and accessed only by research staff who are committed to ensuring
your privacy, and who have signed data privacy pledges.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless the collection of information displays a valid control number assigned by the
Office of Management and Budget (OMB).. The OMB control number for this collection is
3170–XXXX. The collection expires on XX/XX/XXXX. Also, a federal law called the Privacy
Act directs how the federal government treats the personally identifiable information contained
in your answers to these questions. To understand how and when your personally identifiable
information may be shared, you can read the Privacy Act Statement on the CFPB’s website at
www.consumerfinance.gov and search for CFPB.021 Consumer Education and Engagement
Records. Additionally, the CFPB will treat the information received from you consistent with its
privacy regulations at 12 C.F.R. Part 1070, et seq. We anticipate the application form taking
about 10 minutes of your time, and the follow-up survey taking about 40 minutes of your time.
Compensation
You will receive a $30.00 gift card as a token of appreciation for participating in the followup survey, which will be given to you after completing the final telephone survey. These funds
are offered as a way to thank you for completing the outcome survey.
Questions
If you have any questions about the study you can contact the Urban Institute research staff at
(202) 261-5574.
Signature of Subject or Legally Authorized Representative
My rights as a study participant have been explained to me and my signature below indicated
that I understand my rights. I am willing to participate in this study of how financial coaching
programs help participants. I have been given a copy of this form. I understand that by agreeing
to participate in this study I grant the research team of [Survey Organization] 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;
Permission to obtain access to my credit report from a third party credit reporting agency;
Permission for [The Financial Clinic/SFLUM] to share information that I give to [The
Financial Clinic/SFLUM] when I apply for the financial coaching program and
information that [The Financial Clinic/SFLUM] uses to keep track of participants using
their services with the Urban Institute and Consumer Financial Protection Bureau;

Permission to contact [The Financial Clinic/SFLUM] and the individuals I list as contacts
on the application form, in case the interviewer and I lose touch.

Signature

Date

Printed Name

Signature of Staff

Printed name of Staff

Date (must be same as respondent’s)