Scale-up America Initiative Evaluation Study

(OMB Control Number: 3245-XXXX )

Appendix B-2 Participant Intake Survey Consent Form

ScaleUp America Initiative

Survey Consent Form for Participant

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 initiative. Optimal has designed this survey to learn about ScaleUp participants (i.e., people who have received a service from the ScaleUp initiative) and their experience with ScaleUp. Topics in the survey include information about you (the participant), your business, your business needs and goals, the services you received from ScaleUp, and your successes and challenges while participating in the initiative. The primary purpose of this data collection effort is to determine if the initiative is effective and to find ways to improve ScaleUp and other small business assistance programs and initiatives 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 client 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, unless required by law. Your information is subject to the protections of the Privacy Act of 1974, and SBA will not disclose information under the Freedom of Information Act if that information is shown to be a trade secret or information that is commercial or financial in nature and privileged or confidential.

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