Elder Financial Protection Networks Study

Appendix : Informed Consent/Privacy Act Notice for Individual Interviews
The Consumer Financial Protection Bureau (CFPB), a U.S. Federal government agency, has entered into
an interagency agreement with the Library of Congress (LC) Federal Research Division (FRD) to
undertake research and conduct a series of interviews to learn more about existing collaborative efforts
to increase prevention, awareness, and action on senior financial exploitation and abuse.
What is the purpose of this project?
The purpose of this project is to identify the benefits of collaborative efforts to address elder financial
exploitation and abuse, their measures of impact, and key features and practices that can be used in a
replication guide. As part of this project, you have been asked to participate in a one-on-one discussion
that will take no more than two hours of your time.
Privacy
Notice of Collection under the Privacy Act (Privacy Act Statement)
5 U.S.C. 552(a)(e)(3)
The information you provide through your participation and responses will assist the CFPB in learning
more about existing collaborative efforts to increase prevention, awareness, and action on senior
financial exploitation and abuse. Identifying information collected to facilitate the interviews includes
your name, professional affiliation (i.e., job title, work contact information), network affiliation, your
responses and input provided in the discussion, and audio recordings of your participation.
Notes will be taken during the session and the session will be audiotaped and then transcribed to
provide an accurate record of the discussion. The notes and transcripts will be used to create a report
and guide shared with the CFPB and the public. Only project staff members from CFPB and LC/FRD with
access to notes and transcripts will be able to see your responses or to use the audio recordings.
This collection of information is authorized by Pub. L. No. 111-203, Title X, Sections 1013 and 1022,
codified at 12 U.S.C. §§ 5493 and 5512. Information collected will be treated in accordance with the
System of Records Notice (“SORN”), CFPB.021 – CFPB Consumer Education and Engagement Records [77
FR 60382. This information will not be disclosed as outlined in the Routine Uses for the CFPB.021
Consumer Education and Engagement SORN and will otherwise not be shared except to the extent
required by law, in accordance with this notice, or as otherwise outlined in this consent form.
Your participation is voluntary. You are not required to provide any identifying information, and you
may refuse to answer any questions at your discretion or may refuse to have your participation
audiotaped as outlined in this consent form.
Risks
While we will not use your name in the reports or the names of any other person that you share with us,
we may use direct quotes from the interviews, in which case we will only identify people by their role in
the collaborative effort, for example: “law enforcement member in Jefferson County TRIAD, Colorado.”
Therefore, people may be able to attribute ideas or directly to you by name or inference. To mitigate
any risk, we will provide you with an opportunity to review the transcript, delete any information that
makes you uncomfortable, and send the transcript back to us. You may also take that opportunity to add
clarifications or additional information.
There are no questions about demographics, income, age, health, etc. This project only involves you
giving us some information about the network with which you are affiliated and your role in that
network. The project only collects your opinion about the activities, benefits, and effectiveness of that

1

collaborative effort. We recognize that you might be uncomfortable answering some questions, and you
may refuse to answer those questions.
Right to Refuse or Withdraw
Participation is completely voluntary. You may choose not to participate or to discontinue our
conversation at any time for any reason. You may choose not to answer a question for whatever reason.
If you choose to stop the conversation, you have the right to withdraw any part of the conversation that
has already occurred. Refusal to participate involves no penalty or loss of benefits. You may also choose
to not have our conversation audio recorded and still participate in the discussion. Should you allow us
to record the conversation, we will give you the opportunity to review the transcript and to add
clarifications or to delete anything with which you are uncomfortable.
Benefits
Although there are no direct benefits to you, by sharing your thoughts and ideas you will help us and
CFPB better understand how to address senior financial exploitation and abuse.
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and
notwithstanding any other provision of law, a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The OMB control number for this collection
is 3170-0036. It expires on 06/30/2016. The time required to complete this in-person information
collection is estimated to average approximately two hours per response. The obligation to respond to
this collection of information is voluntary. Comments regarding this collection of information, including
the estimated response time, suggestions for improving the usefulness of the information, or
suggestions for reducing the burden to respond to this collection should be submitted to the Consumer
Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by
email to [email protected].
Contact Information
If you have questions about your rights as a participant, you may contact Sandra W. Meditz at the
Library of Congress Federal Research Division at 202-707-2888 or [email protected]. Please sign below to
indicate that you have read the above and agree to take part in this interview.
I have reviewed this form and hereby authorize the Consumer Financial Protection Bureau and the
Library of Congress to record my participation by audiotape, use quotes from this interview, and refer to
my professional affiliation as specified above in the reports and other educational materials arising from
this research project. I accept that no royalties, compensation, or residuals will be paid for this use. I
waive any right to inspect and approve the rough cut, draft, or finished product(s).
Please print your
name:
Please sign your
name:
Witness signature:
Date:

2

Appendix : Informed Consent/Privacy Act Notice for Group Discussion
Participants
The Consumer Financial Protection Bureau (CFPB), a U.S. Federal government agency, has entered into
an interagency agreement with the Library of Congress (LC) Federal Research Division (FRD) to
undertake research and conduct a series of interviews to learn more about existing collaborative efforts
to increase prevention, awareness, and action on senior financial exploitation and abuse.
What is the purpose of this project?
The purpose of this project is to identify the benefits of collaborative efforts to address elder financial
exploitation and abuse, their measures of impact, and key features and practices that can be used in a
replication guide. As part of this project, you will participate in a group discussion that will take no more
than two hours of your time.
Privacy
Notice of Collection under the Privacy Act (Privacy Act Statement)
5 U.S.C. 552(a)(e)(3)
The information you provide through your participation and responses will assist the CFPB in learning
more about existing collaborative efforts to increase prevention, awareness, and action on senior
financial exploitation and abuse. Identifying information collected to facilitate the interviews includes
your name, professional affiliation (i.e., job title, work contact information), network affiliation, your
responses and input provided in the discussion, and audio recordings of your participation.
Notes will be taken during the session and the session will be audiotaped and then transcribed to
provide an accurate record of the discussion. The notes and transcripts will be used to create a report
and guide shared with the CFPB and the public. Only project staff members from CFPB and LC/FRD with
access to notes and transcripts will be able to see your responses or to use the audio recordings.
This collection of information is authorized by Pub. L. No. 111-203, Title X, Sections 1013 and 1022,
codified at 12 U.S.C. §§ 5493 and 5512. Information collected will be treated in accordance with the
System of Records Notice (“SORN”), CFPB.021 – CFPB Consumer Education and Engagement Records [77
FR 60382. This information will not be disclosed as outlined in the Routine Uses for the CFPB.021
Consumer Education and Engagement SORN and will otherwise not be shared except to the extent
required by law, in accordance with this notice, or as otherwise outlined in this consent form.
Your participation is voluntary. You are not required to provide any identifying information, and you
may refuse to answer any questions at your discretion or may refuse to have your participation
audiotaped as outlined in this consent form.
Risks
While we will not use your name in the reports or the names of any other person that you share with us,
we may use direct quotes from the interviews, in which case we will only identify only identify people by
their role in the collaborative effort, for example: “law enforcement member in Jefferson County TRIAD,
Colorado.” Therefore, people may be able to attribute ideas or directly to you by name or inference. To
mitigate any risk, we will provide you with an opportunity to review the transcript, delete any

3

information that makes you uncomfortable, and send the transcript back to us. You may also take that
opportunity to add clarifications or additional information.
There are no questions about demographics, income, age, health, etc. This project only involves you
giving us some information about the network with which you are affiliated and your role in that
network. The project only collects your opinion about the activities, benefits, and effectiveness of that
collaborative effort. We recognize that you might be uncomfortable answering some questions, and you
may refuse to answer those questions.
Right to Refuse or Withdraw
Participation is completely voluntary. You may choose not to participate or to discontinue our
conversation at any time for any reason. You may choose not to answer a question for whatever reason.
If you choose to stop the conversation, you have the right to withdraw any part of the conversation that
has already occurred. Refusal to participate involves no penalty or loss of benefits. You may also choose
to not have our conversation audio recorded and still participate in the discussion. Should you allow us
to record the conversation, we will give you the opportunity to review the transcript and to add
clarifications or to delete anything with which you are uncomfortable.
Benefits
Although there are no direct benefits to you, by sharing your thoughts and ideas you will help us and
CFPB better understand how to address senior financial exploitation and abuse.
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it displays a valid OMB control number.
The OMB control number for this collection is 3170-0036. It expires on 06/30/2016. The time required
to complete this information collection is estimated to average approximately two hours per response.
The obligation to respond to this collection of information is voluntary. Comments regarding this
collection of information, including the estimated response time, suggestions for improving the
usefulness of the information, or suggestions for reducing the burden to respond to this collection
should be submitted to the Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G
Street NW, Washington, DC 20552, or by email to [email protected].
Contact Information
If you have questions about your rights as a participant, you may contact Sandra W. Meditz at the
Library of Congress Federal Research Division at 202-707-2888 or [email protected]. Please sign below to
indicate that you have read the above and agree to take part in this interview.

Please print your
name:
Please sign your
name:
Witness
signature:
Date:

4