HPOG Appendix N Previously Approved Supplementary Documents

Supporting
Statement for OMB
Clearance Request
Appendix N:
Previously Approved
Supplementary
Documents
National Implementation
Evaluation of the Health
Profession Opportunity
Grants (HPOG) to Serve
TANF Recipients and
Other Low-Income
Individuals and HPOG
Impact Study
0970-0394

April 24, 2013

Submitted by:
Office of Planning,
Research & Evaluation
Administration for Children & Families
U.S. Department of Health
and Human Services

Federal Project Officers:
Molly Irwin and Mary Mueggenborg

Appendix N

OMB # 0970-0394
Expiration Date xx/xx/xxxx

Appendix N: Previously Approved Supplementary Documents
HPOG Participant Informed Consent

▌pg. 1

OMB Control No. 0970-0394
Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 08592-100/110-00

AGREEMENT TO TAKE PART IN THE
HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM AND STUDY
This program is part of a new national project to train people for health care jobs. The program is
funded by the U.S. Department of Health and Human Services in Washington, DC. That agency
is also funding research to study how well our program works in helping people get training and
jobs. Over the next several years, researchers will be using information about people in the
program to do their studies. Researchers from Abt Associates and the Urban Institute are doing
the current study. Other researchers may engage in future studies. You are invited to take part in
this important research.
The researchers need your permission to get information about you so they can understand the
types of people in the program and how well the program is working. They want: 1) information
about the training and services you get in the program; (2) information about you and your
family, your education, and work history; and (3) personal data such as your Social Security
number so they can get information from government sources about your future employment,
earnings, education, and public benefits like welfare.
Abt Associates, The Urban Institute and future researchers will use data security procedures to
keep all of the study data private and to protect your personal information. All of the information
used in research will be kept private to the extent allowed by law. Your name will never appear
in any report or with any research findings. The researchers will combine the information about
everyone in the program to analyze how the program helps people find and keep a job in health
care. Any forms or other papers that include your name will be kept in a locked storage area, and
any computer files with your name will be locked and protected. Any researchers using
information to study the program must follow all data security procedures and sign a privacy
agreement.
Participating in research studies is voluntary. You may withdraw your permission to share data at
any time. Refusing to provide permission for research now, or withdrawing permission for
research later, will not affect your eligibility for any services in this program or elsewhere. If you
withdraw, researchers may continue to use information that was collected about you during the
period that you did give permission for research.
By participating in the study, you will help us, the federal government, and programs around the
country learn about the best way to provide training and help participants get a health care job.
You will be asked for information at certain times during your participation in the program and
after you leave the program. You may be contacted by a researcher after you leave the program

1

OMB Control No. 0970-0394
Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 08592-100/110-00

to answer some questions about your experiences. While we encourage you to answer their
questions, you may refuse to answer them.
This agreement is effective from the date you sign it (shown below) until the end of the research
studies or when you choose to withdraw permission.
For questions or concerns about your rights as a research participant, call Teresa Doksum at the
Abt Associates Institutional Review Board at toll-free 877-520-6835. For questions or concerns
about the research, call either Alan Werner (Abt Associates) at 617-492-7100, EXT 2832 (toll
call) or Demetra Nightingale (the Urban Institute) at 202-261-5571 (toll call).
Statement
“I have read this form and agree/do not agree to allow information about me to be used in the
national Health Profession Opportunity Grant Program research studies. I know that my
participation in the research study is voluntary, that Abt Associates, the Urban Institute and any
future researchers will use data security procedures to keep all of the study information private as
described above, and that my name will never appear in any public report. I know that I can
refuse to answer any questions researchers might ask me, and that I can stop being included in
the research at any time without penalty. I understand that Abt Associates, the Urban Institute
and other researchers will use my personal information to get information about me from other
sources, as described above.”

PRINT NAME OF STUDY PARTICIPANT

IF YOU AGREE TO LET RESEARCHERS USE YOUR INFORMATION, SIGN ABOVE
DATE

IF YOU DO NOT AGREE TO LET RESEARCHERS USE YOUR INFORMATION, SIGN ABOVE

DATE

Institutional Review Board
Study Approval Date: 9/30/11
Study Expiration Date: 9/29/12
IRB Study#: 0572

2

Appendix N

HPOG Participant Informed Consent (Spanish)

OMB # 0970-0394
Expiration Date xx/xx/xxxx

ACUERDO DE PARTICIPAR EN
EL ESTUDIO DEL PROGRAMA DE SUBVENCIONES DE OPORTUNIDAD
PARA LAS PROFESIONES DE SALUD [SOPS]

Este programa es parte de un nuevo proyecto nacional para entrenar a personas para trabajos el
área del cuidado de salud.. El programa es financiado por el Departamento de Salud y Servicios
Humanos Estadounidense en Washington, DC. Esta agencia también está financiando la
investigación para estudiar cómo funciona nuestro programa en ayudar a las personas a
conseguir entrenamiento y empleo. En los próximos años, los investigadores van a utilizar la
información acerca de las personas en el programa para hacer sus estudios. Los investigadores de
Abt Associates y el Urban Institute están llevando a cabo el estudio actualmente. Otros
investigadores pueden participar en estudios futuros. Usted está invitado a participar en esta
importante investigación.

Los investigadores necesitan su permiso para obtener información sobre usted para poder
entender cuales tipos de personas están en el programa y qué tan bien está funcionando el
programa. Ellos quieren: (1) información acerca del entrenamiento y los servicios que recibe en
el programa, (2) información sobre usted y su familia, su educación y experiencia laboral, y (3)
los datos personales tales como su número de Seguro Social para poder obtener información de
fuentes gubernamentales acerca de su empleo en el futuro, ingresos, educación, y servicios
públicos, tales como servicios de beneficencia.

Abt Associates, el Urban Institute, y otros investigadores involucrados en el futuro utilizarán los
procedimientos de seguridad de datos para mantener privados todos los datos del estudio y para
proteger su información personal. Toda la información utilizada en la investigación se mantendrá
privada hasta la medida permitida por la ley. Su nombre nunca aparecerá en ningún informe o
con cualquier resultado de la investigación. Los investigadores juntarán la información sobre
todos en el programa para analizar cómo el programa ayuda a las personas a encontrar y
mantener empleo en el área del cuidado de salud. Todos los formularios u otros documentos que
incluyen su nombre se mantendrán en un lugar bajo llave, y todos los archivos de computadora
con su nombre serán protegidos. Todos los investigadores que utilizan la información para
estudiar el programa deben seguir todos los procedimientos de seguridad de datos y firmar un
acuerdo de privacidad.

1

Participación en los estudios es voluntaria. Usted puede retirar su permiso para compartir los
datos en cualquier momento. Negarse a proporcionar el permiso para que la investigación ahora,
o retirar el permiso para que la investigación más tarde, no afectará su elegibilidad para los
servicios de este programa ni en otro lugar. Si retira su participación, los investigadores pueden
seguir utilizando la información recopilada sobre usted durante el tiempo que dio el permiso
para la investigación.

Al participar en el estudio nos va a ayudar a nosotros, el gobierno federal, y programas en todo el
país a aprender acerca de la mejor manera de proporcionar entrenamiento y ayudar a los
participantes conseguir un trabajo en el área del cuidado de la salud. Le pediremos información
en ciertos momentos durante su participación en el programa y después de salir del programa. Es
posible que un investigador se ponga en contacto con usted después de salir del programa para
hacerle algunas preguntas acerca de sus experiencias. Aunque le invitamos a responder a esas
preguntas, usted puede negarse a contestar.

Este acuerdo es efectivo desde la fecha en que usted firme (abajo) hasta el fin de los estudios de
investigación o cuando usted decida retirar el permiso.

Si tiene preguntas o dudas acerca de sus derechos como participante en la investigación, favor de
llamar a Teresa Doksum en la Junta de Revisión Institucional de Abt Associates en el teléfono
libre de cargos al 877-520-6835. Si tiene preguntas o dudas acerca de la investigación, llame a
Alan Werner (Abt Associates) en el 617-492-7100, EXT 2832 (llamada de larga distancia con
cargo) o Pamela Loprest (el Urban Institute) en el 202-261-5659 (llamada de larga distancia con
costo).

2

Declaración
“He leído esta forma y [estoy de acuerdo / no estoy de acuerdo] en permitir que mí información
se utilice en los estudios del programa de subvenciones de oportunidad para las profesiones de
salud [SOPS]. Yo sé que mi participación en el estudio de investigación es de carácter
voluntario, que Abt Associates, el Urban Institute y cualquier otro investigador involucrado en el
futuro seguirán los procedimientos de seguridad de datos para mantener toda la información del
estudio privada, como se ha descrito anteriormente, y que mi nombre nunca aparecerá en ningún
informe público. Sé que puedo negarme a contestar cualquier pregunta que los investigadores me
podrían preguntar, y que puedo dejar de ser incluido en la investigación en cualquier momento
sin penalización. Entiendo que Abt Associates, el Urban Institute y otros investigadores
utilizarán mi información personal para obtener información de parte de otras fuentes, como se
describió anteriormente.”

NOMBRE [LETRA DE MOLDE]

SI ESTA DE ACUERDO Y LOS INVESTIGADORES TIENEN SU PERMISO DE USAR SU INFORMACION,
FIRME ARRIBA

FECHA

SI NO

ESTA DE ACUERDO Y LOS INVESTIGADORES

NO

TIENEN SU PERMISO DE USAR SU

INFORMACION, FIRME ARRIBA

FECHA

3

Appendix N

ISIS Informed Consent

OMB # 0970-0394
Expiration Date xx/xx/xxxx

Agreement to Take Part in the
Innovative Strategies for Increasing Self-Sufficiency (ISIS) and
Health Profession Opportunity Grant (HPOG) Studies
ISIS and HPOG are two important studies of services that may help people improve their skills, find a
job, and advance in their careers. Both studies are funded by the U.S. Department of Health and Human
Services.
ISIS is a study looking at the effectiveness of career pathways programs designed to help people improve
their careers in a number of occupations. A research organization called Abt Associates is conducting the
ISIS study. ISIS expects to recruit 10,800 people across 9 different programs to be in the study.
HPOG is a study of programs training people for jobs in health care. Abt Associates and The Urban
Institute are conducting the HPOG study. HPOG expects to recruit over 30,000 people to be in the study.
[Name of site] is trying innovative approaches to help individuals improve their education and
employment outcomes. To learn about how well the program is working, researchers will compare
participants who receive the innovative program services to those who receive other services. Other
researchers may engage in future studies. Your participation in the studies is voluntary. You can end your
participation at any time. There are no penalties for declining to participate. We hope you will agree to be
in these studies. It will help us learn how well the program is working and how to improve services for
future participants.

What Does Participation Mean?
If you agree to be in the study, we will assign you to one of two groups. One group will be able to
participate in [Program Name]. The other group will not be able to participate in this program but may be
eligible for other services in the community. We will use a lottery-like procedure to determine which
group you will be in. This procedure makes sure that assignments are fair. Everyone who agrees to join
the study has the same chance of receiving [Program Name] services. People who are not selected for this
program can re-apply after a period of 48 months. If you decide not to participate in the study, you will
not be able to get these services at [name of site]. If you are not selected for the program or decline to
participate, you will be given a list of other resources available in the community.
If you agree to be in the study, ISIS and HPOG researchers and program staff will collect information
from you to help understand how well the services you receive are working. We will ask you to fill out
two forms today. They will take about 38 minutes to complete. They will ask about your educational
background, family structure, work history, and other experiences. You may feel that some questions are
personal or sensitive. The information will help us to understand what contributes to people’s success,
and we encourage you to provide it. You may refuse to answer any question. Your answers will not affect
your placement into the program or non-program group. In exchange for your time, we will provide you
with a $25 gift card before you leave today.
ISIS and HPOG researchers will collect additional information about you in the future, regardless of
which group you are in. This information will help us understand how well the program is working.
1) We will ask you to participate in one or more additional surveys sometime in the next few years.
You will receive a payment for your time completing each additional survey. You can refuse to
participate in the interviews or answer any of the questions.

2) We will collect information about you, including data maintained by this program, other schools,
your employer, and government agencies. This information may include information about
government services you have received, such as TANF or SNAP (food stamps) and employment
records. We will collect records from schools you have attended including but not limited to grades
and test scores, coursework, support services, and financial aid. To do this, we need to collect your
Social Security Number.
3) We are interested if programs like [name of site] benefit children. If you have children, we may
collect information about them from school records and other agencies. We also may ask your
permission to talk with or observe your children. Your participation in these activities is voluntary.
You or your children can choose to stop participating at any time.

If you withdraw, researchers may continue to use information that was collected about you
during the period that you did give permission for research.
Potential Risks
We are committed to keeping your personal information private. All information you provide will be
protected under the federal Privacy Act of 1974. Only the interviewer and authorized project staff and
researchers evaluating the new programs will see your survey responses. However, there is a small risk of
a breach of privacy. We will take strong precautions to make sure this does not happen. We will keep any
paper that includes your name and other personal information in a locked storage area and destroy the
files after the study ends. We will password protect any computer files with personal information and
store them on a secure network.
We will give the Department of Health and Human Services a dataset with your answers but not your
name or anything that might identify you such as date of birth, Social Security Number, address, or phone
number. The information we give to the Department of Health and Human Services will not be available
to the public. Your personally identifiable information, like your name or the names of your children, will
not appear in any public document produced as part of the study. Your information will be used only for
the purpose of the study and will be kept private to the extent allowed by law.

Questions about participation
If you have any questions about the study, contact Karen Gardiner, ISIS Project Director, at
[email protected] (email) or 301-634-1700 (phone). If you have any questions about your rights as a
study participant, contact Teresa Doksum with the Abt Associates Institutional Review Board at
[email protected] (email) or 877-520-6835 (toll-free).

Agreement to Participate
By signing this participation agreement, I confirm that I have read and understand the description of the
ISIS and HPOG studies. I have had the opportunity to ask questions. I understand I will be put into one of
two groups at random. One group will get the innovative program services. The other group will have
access to other services. I understand that my participation is voluntary. I understand that I can refuse to
answer any questions or stop being in the study at any time without penalty. I understand that I will be
given a copy of this consent form to keep. I understand that Abt Associates and The Urban Institute will
get information about me as described above. I understand that researchers may ask me for permission to
talk with or observe my children. I understand that participation in these activities is voluntary. I

understand this information will be used only for the purpose of the study and will be kept private to the
extent allowed by law.

Participant:
______________________________________
Name of Participant (Printed)

____________________________________
Signature of Participant
Date