Consent Form for Interviews - Michigan Site

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix A-8: Consent Form for Interviews—Michigan site

Michigan Recession and Recovery Study

Family Coping Strategies Supplement

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 continue your participation in a research study conducted by Sarah Burgard, Sheldon Danziger and Kristin Seefeldt from the Gerald R. Ford School of Public Policy at the University of Michigan. This phase of the study- the “Family Coping Strategies Supplement” is currently funded by the U.S. Department of Health and Human Services via a subcontract from the Urban Institute (Washington, D.C.) to the University of Michigan.

• The purpose of this research study is to continue learning 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 and the supplement is completely voluntary.

• If you participate, you will be interviewed and asked detailed questions about your current employment status, your living arrangements, your 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. As a token of our appreciation for your participation, you will receive $40 at the start of the interview. The researchers are planning to conduct at least one additional survey within the next two years, depending upon future funding. If you participate, you agree to be contacted for the next survey. Being contacted in the future does not mean that you have to participate again. You may decline further participation when re-contacted.

• If you participate, you agree to the audio taping of the interview. The recording of your interview will be kept in secured files on secure computer space. Only authorized project staff 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, any services you may receive or your job 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 providing information that 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:

• Your answers will be kept private. The researchers plan to publish the results of this study. When the researchers present information from the surveys in reports, papers or presentations, it will usually be in an aggregate form, but will never identify you. If the researchers use quotations from this interview or describe your situation, they will use a pseudonym (a different name), and other potentially identifying information about you will be changed in order to protect your privacy. The researchers will also send you summaries of major findings, and this information will also be presented in an aggregate form.

• There are some reasons why people other than the researchers may need to see information you provided. This includes organizations responsible for making sure the research is conducted safely and properly, including the University of Michigan and government offices, such as the study sponsor, the U.S. Department of Health and Human Services.

• To protect your privacy, the researchers have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, to any federal, state, or local civil, criminal, legislative or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, except as explained below.

A Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive information, then the researchers may not use the Certificate to withhold that information. The Certificate of Confidentiality does not prevent the researchers from disclosing voluntarily, without your consent, information that would identify you as a participant in the research project under the following circumstances: a threat of harm to yourself or to others.

• Answers and information you provide in subsequent surveys may be linked together and used in analysis, reports, and papers. However, individual responses will never be used.

• 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 data collection period. After all of the surveys are completed, only the researchers will have access to the identification code.

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

If you have questions about this study, including scheduling or your compensation for participating, you may contact the study director, Sarah Burgard, Michigan Recession and Recovery Study, University of Michigan, P.O. Box 1248, Ann Arbor, MI, 48106-1248, or Kristin Seefeldt, research team member at 734-615-2113 or [email protected].

If you have questions regarding your rights as a research participant, or wish to obtain information, ask questions, or discuss any concerns about this study with someone other than the researchers, please contact the University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board, 540 East Liberty Street, Suite 202, Ann Arbor, MI, 48104-2210, (734) 936-0933, toll-free at (866) 936-0933, or via email at [email protected]

Signing this consent form indicates that you understand and are willing to participate in this study.

Respondent’s Name _________________________________________

Respondent’s Signature _________________________________________

Date _________________________________________

 I received the $ 40 token of appreciation.  I refused the $ 40 token of appreciation.

_________________________________ ________________________________
Respondent’s Signature Respondent’s Name (PLEASE PRINT)

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

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