Appendix W1
OMB Control No. 0970-0413
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.
MDRC
INFORMED CONSENT FORM
AGREEMENT TO PARTICIPATE IN THE “Paycheck
plus STUDY”
You are invited to take part in the Paycheck Plus study. A nonprofit research company called MDRC is running the study. This form describes the Paycheck Plus study and explains what it means for you to be a part of it. When you sign this form, you agree to be in the Paycheck Plus study and you allow MDRC to collect certain types of information about you. MDRC needs this information to conduct the study. Your participation in the study is voluntary. Before signing this agreement, you may ask questions about anything you do not understand. We hope you will agree to participate.
What is the Paycheck Plus study?
The study will test whether a yearly bonus, based on earnings from work, will increase employment, earnings, and income. The bonus will be up to $2,000 and offered each year after you file taxes in 2017, 2018, and 2019.
Who is eligible for the Paycheck Plus study?
You can sign up for the study if:
You are at least 21 and less than 65 years of age;
You didn’t work or earned less than $30,000 last year;
You are not married;
You do not have any children or if you do, you do not plan to claim them as dependent children this year;
You are not currently receiving or applying for SSI or SSDI;
You have a social security number; and
You sign this Informed Consent and Agreement to Participate Form.
What does it mean to be in the Paycheck Plus study?
You have a chance to earn the yearly bonus. Half of the people who sign up for the study will be assigned to a group that is given the chance to earn the bonus. The other half of people who sign up will not. How you are assigned happens by chance and it is like flipping a coin. It is not based on anything about you or your background. If you are eligible and agree to be in the study, you will be randomly assigned by a computer program to one of two groups:
The “Paycheck Plus Group”. Members of the Paycheck Plus Group will be offered a chance to earn a bonus of up to $2,000 each year after they file a tax return in 2017, 2018 and/or 2019.
The “Control Group”. Members of the Control Group will not be offered the chance to earn the bonus in 2017, 2018 or 2019. They can file their taxes and get any credits or refunds that they are eligible for.
What information will the research team collect?
The research team will collect information on you for up to eleven years.
Personal and background information. After you sign this form, you will be asked to provide your name, date of birth, and social security number. This will be used to collect information about you for the study. The research team will also ask you about your race or ethnicity, education, gender, employment history, arrest history, any children you might have, and whether you filed taxes last year. This form takes about 15 minutes to complete.
Contact information. After you sign this form, you will be asked to provide your address, phone number, and other information like email address that may be used to contact you. This form takes about 5 minutes to complete.
Follow-up surveys. In the future, you may be contacted to complete one or more survey interviews. These surveys are voluntary and you do not have to answer any questions that make you feel uncomfortable
Tax return information. The research team will collect information on any tax return that you file in 2016, 2017, 2018, and/or 2019. If you are assigned to the Paycheck Plus Group, this information will be used to determine the amount of the bonus that you earned.
Public assistance information. When you sign this form, you allow the Georgia Department of Human Services (DHS) to give MDRC and its subcontractors information about any Cash Assistance (CA) and/or Supplemental Nutrition Assistance Program (SNAP) benefits you and/or your children receive.
DHS will provide MDRC your name, social security number, mailing address, phone number, email address, gender, household composition, case number, case type, case status, and the amount of SNAP and CA benefits you received for one year before and 5 years after you joined the study. MDRC will use this information to understand how well the earnings bonus works and will not share it with anyone outside the research team.
Child support information. When you sign this form, you allow DHS to give MDRC and its subcontractors child support information about you, including the amounts of any child support payments that you make and any child support that you may owe.
Employment and earnings information. MDRC will collect information on your employment and earnings from the Georgia Department of Labor (DOL). MDRC will also collect employment and earnings from the National Directory of New Hires (NDNH) database.
Other information:
MDRC will collect contact information from United Way to get in touch with and to give you program information.
MDRC may collect criminal and incarceration records from state and city agencies.
How will my information be kept private?
The research team will follow strict rules to protect your privacy. All research staff working on this project are trained to protect private information. Any papers that include your name or other private information will be kept in a locked area. Any computer files with your name or other private information will be securely stored and protected by a password. Only a small number of trained research staff will be able to see your private information. Your name will never be used in any report written for the project. All private information about you will be destroyed two years after the end of the study.
If you tell the research team about someone being harmed or that you want to harm someone, we will have to report it to the authorities. Also, we may have to give up information about you if a court orders us to do so.
What are the benefits and risks of participating in the Paycheck Plus study?
When you participate in the study, you can help researchers and policymakers. You can help them learn whether offering a bonus increases employment, earnings, and income. You can also help them find better ways to support workers.
The risks of participating are small. You do not have to answer any questions that make you uncomfortable. We have taken many steps to prevent what you tell us from being shared with others.
If you are assigned to the Paycheck Plus Group, your earnings bonus may be counted as income for public benefits budgeting purposes.
If you are assigned to the Control Group, you will still have a chance to file taxes and earn credits that you would normally be eligible for, but you will not be able to earn the bonus in this study.
How can I withdraw from the Paycheck Plus study?
The decision to be in the study is your choice. However, only people who enroll in the study will have a chance to be assigned to the Paycheck Plus Group and be eligible to earn the bonus. You can drop out of the study at any time by contacting MDRC (see below). If you drop out of the study, or the study is ended, the study team may use any information collected while you were in the study. Also, if the study is ended or you withdraw, you will no longer be eligible to earn the earnings bonus. Earnings bonus payments are subject to funding availability and are not guaranteed by United Way or MDRC.
Who can I call with questions?
If you have any questions about this study or about your rights as a research subject, or if you want to drop out of the study, you may call MDRC’s Paycheck Plus hotline at 212-340-4480 or you may contact Gilda Azurdia, by e-mail at [email protected] or by phone at 1-800-221-3165.
Statement “I have read this form and agree to be in the Paycheck Plus study. I know that my participation is voluntary and that MDRC and United Way will follow strict rules to protect my privacy. I know that I can refuse to answer any questions or stop being in the study at any time. I understand that the research team will collect information about me from city and state agencies, as described above, and that they will use my social security number, name, and date of birth to collect this information. I understand that MDRC will use my records only for the purposes of conducting research on the Paycheck Plus study and not for any other purposes without my prior written consent. I hereby consent to the sharing of information about me between the agencies as described above in this consent form.
____________________________ Name of Study Participant (Print)
________________________________ ____________________________ Signature of Study Participant Date |
MDRC ICF Paycheck Plus ATL 05/21/2015
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Rachel Pardoe |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |