Scale-up America Initiative Evaluation Study

(OMB Control Number: 3245-XXXX )

Appendix B-6 Comparison Group Survey Consent Form

ScaleUp America Initiative

Survey Consent Form for Comparison Group Member

The U.S. Small Business Administration’s (SBA’s) Office of Entrepreneurial Development (OED) has contracted Optimal Solutions Group, LLC (Optimal), to conduct an independent impact evaluation of the ScaleUp America small business assistance initiative currently underway in your business community. As part of the evaluation effort, Optimal has designed this survey to learn more about business owners in your community who are not currently participating in ScaleUp. Topics in the survey include information about you (the comparison group member), your business, your business needs and goals, and your challenges as a small business owner. The primary purpose of this data collection effort is to determine if the ScaleUp initiative is effective and to find ways to improve small business assistance funded by SBA.

Confidentiality and Usage

Optimal will securely store, tabulate, and analyze survey responses. Any information provided in this survey will be kept strictly confidential by Optimal. In the context of this survey, confidentiality is defined to mean that no respondent will be identified or named in any publicly available report or other such publication. In any public report, such phrases as “a ScaleUp comparison group member noted that…” will be used to report information provided by a particular respondent. Your information will not be shared with parties outside of Optimal and the funding agency, SBA.

Storage and Access

The results from the survey will be stored on a secure server accessible only to the Optimal research team. The survey data will be retained at Optimal for no fewer than 3 years after the completion of the surveys. Survey data with identifying information will be transferred to SBA using encrypted files and/or connections.

If you understand and agree with the conditions described here, please check the appropriate box and type your full name below. Typing your name will grant the Optimal research team permission to conduct the survey as described for the above-referenced study. The research team will not use the information provided for any reason without your permission other than those stated in this consent form.

1. I do not consent

2. I consent

_______________________________

Signature