Consent Form For Interviews - Los Angeles Site

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix A-4: Consent Form For Interviews—Los Angeles site

Public reporting burden for this collection of information is estimated to average 12 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information collection is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer (Attn: OMB/PRA 0970-XXXX), Administration for Children and Families, Department of Health and Human Services, 370 L'Enfant Promenade, S.W., Washington, D.C. 20447.

The following statements describe the research in which you are being asked to participate and tells you your specific rights and our responsibilities:

• You are being invited to participate in a research study called “Family Coping Strategies,” conducted by Dr. Pamela Loprest and Dr. Heather Sandstrom at the Urban Institute, a non-profit research organization in Washington, D.C., in partnership with Dr. Kristin Seefeldt from the University of Michigan. This study is currently funded by the U.S. Department of Health and Human Services.

• The purpose of this research study is to learn how individuals and households are managing during an economic downturn in terms of employment, finances, housing, health, mental health, and relationships.

• Participation in this study is completely voluntary.

• If you participate, you will be interviewed and asked detailed questions about your current employment status, living arrangements, household finances, your health, mental health, and relationships. You may consider some of these questions personal and sensitive, but the researchers have taken many steps, outlined below, to protect your privacy.

• Answering questions or talking with others about some of these sensitive issues can be difficult. You may choose not to answer any question and you can stop your participation at any time; all you have to do is say, “I want to stop.” At the end of the interview, the interviewer will provide you with a list of local social service agencies, including health and mental health providers, organizations that help with food, and agencies that can provide referrals for other types of services.

• The interview will last about 90 minutes depending on your responses. As a token of appreciation for your time, you will be offered $40 at the start of the interview.

• If you participate, you agree to the audio recording of the interview. The digital recording of your interview will be kept in secured files at the Urban Institute. Only authorized project researchers are allowed access to recorded interviews. The content of the interviews will be typed into a word processing file, with only the identification code, and not your name, used in the file. Once the project is complete, all recordings will be destroyed.

• Your family, your job, and any services you may receive will not be affected in any way by participating or choosing not to participate in this study.

• The researchers have taken steps to minimize the risks of this study. Even so, you may still experience some risks related to your participation, even when the researchers are careful to avoid them. These risks may include feelings of discomfort when providing information you consider to be personal and sensitive.

• Although you may not benefit directly from this study, your participation will help us understand the issues faced by families like yours so that the state and federal government can design better programs, policies, and services.

The research team will take the following steps to protect your privacy:

• Everyone who works on this study has signed a Staff Confidentiality Pledge requiring them not to disclose anything you say during the interview in such a way that someone outside the research team can identify you. The only exception is the researcher may be required by law to report suspicion of harm to yourself, to children, or to others.

• Your name and contact information will be kept in secure files separate from the answers you provide. The only way to connect your name with your answers is an identification code, which by itself does not identify you. Only the researchers will have access to your name and your identification code during the study.

• The data you provide will be kept in secure, password protected files with your name and other identifying information removed. You agree to allow researchers to keep the data you provide for use in data analysis. The researchers may keep the data after the study ends.

• The researchers plan to publish the results of this study in reports, papers and presentations. Your answers will be kept private, meaning your identity will never be revealed in the results. If the researchers quote anything you say during this interview or describe your situation, they will use a different name for you, and any potentially identifying information about you will be changed in order to protect your privacy.

If you have questions about this study, you may contact the project leader, Heather Sandstrom at the Urban Institute, 2100 M Street NW Washington, DC 20037, (202) 261-5833 or [email protected].

Signing this consent form indicates that you understand the terms of this agreement and are willing to participate in this interview and have the interview audio recorded.

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Respondent’s Name (PLEASE PRINT)

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Respondent’s Signature Date

You will be given a copy of this form for your records.

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