Consent Form

AGREEMENT TO TAKE PART IN THE

U.S. DEPARTMENT OF LABOR JOB TRAINING EVALUATION

You are invited to take part in an important voluntary study of job training services. The study is funded by the U.S. Department of Labor. It will test how well our program works to help individuals improve their skills, and find and keep a job. [Name/s of evaluator/s] are running the study for the U.S. Department of Labor. Your participation will help us learn more about the benefits of these programs.

Under this study, everyone applying to this program will be assigned to one of two groups. (1) A group that receives job training services provided by [put in specific site or program name], or (2) a group that does not. We will use a lottery to make sure that people are assigned to the two groups in a fair way. There are limited openings in this program. Assigning people to the groups using a lottery ensures fairness. The decision about who goes to which group has nothing to do with personal traits like your age or race.

Your participation in the study is voluntary. If you decide not to participate, this will not affect your eligibility for any other services here or elsewhere. However, you will not be able to apply to this program. You may withdraw from the study at any time without penalty. If you are in the group that receives the training program and you decide to withdraw from the study, you may continue to participate in the program. If you are in the group that does not receive the training program and you decide to withdraw from the study, you will not be able to enroll in the program.

What does it mean to be in the study?

To have a chance at enrolling in this job training program, we will ask you to participate in certain activities. You will have to provide some information about yourself. You will also have to participate in the lottery that determines who will be in the program and who will not. Everyone who enters the lottery will be in the study. If you choose not to be in the study, you cannot enroll in this training program. You can still enroll in other programs or services here or elsewhere.

If you agree to be in the study, the researchers will collect several kinds of information about you. This information will help them to understand how well the program is working. This information will be collected whether you are placed in the group that receives the training program or the group that does not.

(1) The researchers will phone you to ask questions about your education, work, family, and other topics. They will call twice: 1½ years and 3 years from now. You will receive a payment for the time you spend completing each interview. You can refuse to participate in the interviews or answer any of the questions.

Public Burden Statement, OMB 1205-0NEW, expires xx/xxxx

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply is required to obtain benefits under P.L 111-5.  Public reporting burden for this collection of information is estimated to average 3.5 minutes per response, including the time for reading instructions, and completing and reviewing the requested information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy Development and Research, Room N-5641, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-xxxx).

(2) The researchers will use your name, date of birth, and/or Social Security Number to collect information about your employment and earnings history from Unemployment Insurance records or other sources.

(3) The researchers will use your name, date of birth, and/or Social Security Number to collect information about your participation in this program (if you are assigned to the group that receives the training program) and/or about services you receive from other training organizations in the community. Information collected from other organizations may include details on enrollment dates and types of services received.

Risks and Benefits of Participation

Your participation in this study will help the U.S. Department of Labor learn about the best ways to help individuals improve their skills and find jobs. The research organizations conducting this study are committed to keeping your personal information private. There is a small risk of a breach of privacy, however, strong precautions will be taken to protect your information. Any piece of paper that includes your name will be kept in a locked storage area and will be destroyed after the study ends. Any computer files with your name will be protected by a password and will be stored on a secure network. Your personal information will be protected to the extent provided by law. A total of 6,000 individuals will participate in this study. We will only report your information in statistics that include information from others in the study.

Questions

If you have questions about this study, please contact [name of site contact or liaison to be added] at [contact information to be added].

If you have any questions about your rights as a study participant, please contact [name of evaluator] at [evaluator contact number] (toll free).

Consent to Participate

I have read and understood the description of the U.S. Department of Labor Job Training Evaluation. I understand that I will be put into one of two groups - either a group that will receive job training services offered through this program or a group that will not. The group to which I am assigned will be picked by lottery. I know that my participation is voluntary. I understand that [name/s of evaluator/s] are strongly committed to keeping my personal information private. My personal information will be protected to the extent provided by law. I know that I can refuse to answer any questions in the study’s interviews, or stop being in the study at any time without penalty. I understand that [name/s of evaluator/s] will obtain information about me, as described above.

Print Name: _______________________________________________________________________

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Signature: ___________________________________________________ Date: ________________