Att. A Consent Statement

OMB No.: xxxx-xxx

Expiration Date: xx/xx/20xx

ATTACHMENT A:

HARD COPY OF CONSENT INFORMATION

CHILD SUPPORT NONCUSTODIAL PARENT EMPLOYMENT DEMONSTRATION

(CSPED)

This handout will be provided to participants in hard copy by the intake worker during the intake process. Formal consent will be administered during the CATI interview, which follows the intake process. The consent will be read to the participant by the interviewer, and the participant will acknowledge consent verbally on the telephone.

OMB No.: xxxx-xxx

Expiration Date: xx/xx/20xx

CONSENT INFORMATION SHEET

[INSERT STATE PROGRAM NAME]

Child Support Noncustodial Parent Employment Demonstration (CSPED)

This document describes [INSERT STATE PROGRAM NAME HERE] and the Child Support Noncustodial Parent Employment Demonstration (CSPED) study. It is a written copy of information that an interviewer will share with you over the telephone later, if you decide you are interested in being part of the [INSERT STATE PROGRAM NAME HERE] and the CSPED study.

[INSERT STATE PROGRAM NAME HERE] IS PART OF A NATIONAL STUDY

The [INSERT STATE PROGRAM NAME HERE] program is part of the CSPED study, a national study being conducted by the U.S. Department of Health and Human Services. The Department of Health and Human Services has asked a research team from the University of Wisconsin and Mathematica Policy Research to help with the study.

WHAT IS THE STUDY ABOUT?

The main purpose of this study is to better understand if [INSERT STATE PROGRAM NAME HERE ] helps parents like you. We are interested in whether the program helps noncustodial parents pay their child support by providing additional services that work better together. These include child support services, employment services, and parenting activities. Through the study, we hope to learn if these extra services address families’ needs and how they could be improved.

HOW WILL PROGRAM PARTICIPANTS BE CHOSEN?

The chance to get these extra services through the [INSERT STATE PROGRAM NAME HERE] is available only to those noncustodial parents who agree to take part in the study. If you want to be eligible to receive these extra services, you have to agree to be a part of the CSPED study.

If you decide that you do not to be in the study, you will not have a chance to receive the extra services and will receive regular or the “usual” services that you could receive even if this study was not being done.

Public Burden Statement:  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.  The OMB control number for this project is [FILL NUMBER].  Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: ACF Reports Clearance Officer [FILL ADDRESS].

Because space is limited and we cannot provide extra services to all the parents who would like to get them, the research team created a computer program to randomly select which parents who want to be in the study will also get the extra services. If you agree to be a part of the study, the computer will place you into one of two groups: one group will receive the extra services through the [INSERT STATE PROGRAM NAME HERE] at no cost to them; the other group will not receive services beyond the regular or “usual” services they could get even if the study was not being conducted. The computer works like a flip of a coin; you will have a 50 percent chance of being assigned to the group that receives the extra services through the [INSERT STATE PROGRAM NAME HERE] and a 50 percent chance of being assigned to the group that receives regular or “usual” services. The process is random and the chance of being selected to receive extra services is not influenced by what you say to me or the staff at the University of Wisconsin or Mathematica Policy Research.

If you decide to participate in the study, I will ask you to complete a short interview on the telephone today. A staff member from [PROGRAM NAME] will let you know which group you are in after today’s interview.

WHAT HAPPENS IF I AM NOT SELECTED TO RECEIVE EXTRA SERVICES?

If you are not randomly selected to receive extra services, you will be eligible for regular or “usual” services, just like if the study were not being conducted. It is important that you understand that even though you are not receiving the extra services through [INSERT STATE PROGRAM NAME HERE], you will still be part of the study so that researchers can compare your experiences to those who are selected to receive the extra services. In order to be able to do this, the researchers will collect and track information about you.

WHAT DOES PARTICIPATION INVOLVE?

If you decide to take part in the study, you will complete an interview on the phone today. The interview will take about 30 minutes. The interview may be recorded for quality control purposes. If a recording is made, it will not be shared with anyone outside the research team and will be destroyed after the study is finished.

Then, whether or not you are selected to receive the extra services, the researchers will contact you again in about one year to update some of the information you give us today and ask some new questions. This second interview will also take about 30 minutes. You may also be asked to participate in focus groups as a part of this study. Participation in a focus group will take about 90 minutes of your time.

Further, if you agree to be in the study, regardless of whether you are in the group that receives the extra services or the group that receives the regular or “usual” services, you are agreeing to allow the research team to contact federal and state agencies for information about your employment and earnings, child support orders, experiences with the criminal justice system and child welfare system, and other benefits or services you may receive from public programs, and to obtain a copy of your credit report. It also means that you agree it is okay for staff of [INSERT STATE PROGRAM NAME] to share information with the study team about you and the services you receive.

At any time, after you have been placed in a group, you can call our study helpline to say that you no longer want the program to share information about you with the researchers. If you choose to do this, it will have no effect on the services available to you. However, by agreeing now to be in the study, even if later you tell us you want to withdraw from the study, you are authorizing researchers to use information about you before you withdrew.

WILL MY PRIVACY BE PROTECTED?

This information the research team collects about your employment and earnings, child support agreements, criminal background, credit rating, and other benefits or services you may receive from public programs, and everything you tell the program staff or the interviewers will be kept private and will not be shared with anyone. However, if you tell a person on the study team about child abuse or if you threaten to harm yourself or someone else, it must be reported by law.

This study also has a Certificate of Confidentiality from the National Institutes of Health. This means that we will not share information that could identify you, even if a court asks us to, unless the U.S. Government demands information to audit or evaluate federal projects or to meet the Food and Drug Administration’s requirements.  This certificate does not stop you from choosing to share information about yourself or your part in this study.

The information from all study participants will be combined and written up in a report to the U.S. Department of Health and Human Services. Researchers might use information from this study in journals, books or presentations. However, nothing will be said about you as an individual. Instead, information about you will be combined with information about everybody else in the study, so the researchers can say things like “30 percent of parents in the program have two children.”

WHAT ARE THE BENEFITS OF PARTICIPATING IN THE STUDY?

If you are assigned to the group that receives the extra services, you will receive these services, which could better enable you to pay your child support. If you are assigned to the group that is eligible to receive regular or “usual” services, you will not benefit from receiving the extra services. However, your participation will help the Department of Health and Human Services learn how to better provide services in the future to other parents like you.

WHAT ARE THE RISKS OF PARTICIPATING IN THE STUDY?

There is minimal risk related to taking part in this study. In the unlikely event that there is a breach in confidentiality, your participation in a public benefit program could become known. There is also a risk that you may feel uncomfortable answering some questions in the interviews about your relationships, income, program participation, and barriers to employment (such as drug or alcohol use and past contact with the criminal justice system).. You can refuse to answer those questions if you wish, and it will not change the services you receive.

WILL I BE COMPENSATED FOR MY PARTICIPATION?

If you decide to participate in the study and complete today’s interview, you will receive a $10 gift card. You will receive an additional $25 gift card if you participate in the follow-up interview. You would receive a $20 gift card if you participate in a focus group. Whether or not you take part in the follow-up survey and focus groups is up to you and will have no effect on the services you receive.

WHAT IF I HAVE QUESTIONS ABOUT THE STUDY OR MY PARTICIPATION IN IT?

You may ask any questions about the study at any time. If you have questions about the study, you can contact the Principal Investigators, Maria Cancian or Dan Meyer at the University of Wisconsin, at 608‑262‑6358.

If you are not satisfied with their answers, have more questions, or want to talk with someone about your rights as a participant in this study, you can contact the Education Research and Social & Behavioral Science IRB Office at the University of Wisconsin at 608-262-2320.

Review of Consent to Participate in

Child Support Noncustodial Parent Employment Demonstration (CSPED)

• I have been informed of the extra services offered by the [INSERT STATE PROGRAM NAME HERE] program, and I want to receive those services.

• I understand that, in order to be eligible for the extra services available through the [INSERT STATE PROGRAM NAME HERE], I must agree to participate in the Child Support Noncustodial Parent Employment Demonstration (CSPED) Study.

• I understand that I have a 50 percent chance of being placed in the group of parents that receive the extra services through the [INSERT STATE PROGRAM NAME HERE] and a 50 percent chance of being placed in the group of parents that does not receive the extra services. I understand that I am part of the study regardless of the group to which I am assigned.

• I agree to answer a set of questions now. I can choose to participate in later study activities when the researchers contact me in 12 months. I understand that I may be asked some questions about personal things, but I will not have to answer any questions that make me feel uncomfortable. I can change my mind about participating at a later time, and this will not affect the services I receive.

• I give permission for the study team to collect information on the services I receive. I give permission for [INSERT STATE PROGRAM NAME HERE] staff to release information to the study team about me, whether or not I am selected to receive extra services through [INSERT STATE PROGRAM NAME HERE].

• I give permission for the researchers to contact federal and state agencies for information about my employment and earnings, child support agreements, experiences with the criminal justice system, and other benefits or services I receive from public programs, as well as to obtain a copy of my credit report. I understand that this information will be collected whether or not I am selected to receive extra services through [INSERT STATE PROGRAM NAME HERE].

• I understand that all information will be protected.

• I can call the Principal Investigators, Maria Cancian and Dan Meyer, at 608-262-6358, to get an answer about any questions I may have.

• If I have questions about my rights as a research volunteer, or feel that I have been harmed in any way by participating in the study, I can contact the Office of the Education Research and Social and Behavioral Science Institutional Review Board at the University of Wisconsin Institutional Review Board, at 1-608-263-2320.