Veterans Focus Groups

APPENDIX F
VSS CUSTOMER CONSENT FORM

This page has been left blank for double-sided copying.

OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/20xx

VETERANS SUPPLEMENTAL STUDY
CONSENT TO PARTICIPATE
The U.S. Department of Labor is sponsoring a study of some of its employment and training programs
that serve adults and dislocated workers to learn how well these programs are working and how they can
be improved. As part of this national study, called the Workforce Investment Act (WIA) Adult and
Dislocated Worker Programs Gold Standard Evaluation, the department is also undertaking a Veterans
Supplemental Study to learn specifically about the services provided to veterans. The study is being
conducted by a team of researchers at Mathematica Policy Research, Social Policy Research Associates,
and MDRC.
By signing this consent form, you are agreeing to take part in this very important study. As a participant in
this supplemental study, the following will happen:
•

You will complete a short form to provide a description of your background, military service, and
current employment status.

•

You will participate in a group discussion with researchers and other veterans to talk about your
experiences with the American Job Center and the employment and training services you have
received.

•

Researchers may access your case file to learn more about the employment and training services
that you have received.

The decision to participate in the study is up to you. All information that is collected about you through
interviews or agency records will be kept private to the extent allowed by federal law and will be used for
research purposes only. Your name will never be used in any reports and no information will be reported
in any way that can identify you. You may also refuse to answer any questions in the short form or during
the group discussion.

I have read this consent form (or it has been read to me). I understand the information provided in
these materials and voluntarily agree to participate. If I have questions I can call the study toll-free
number at 1-800-925-0356.
__________________________________________
CUSTOMER’S NAME (Printed)

__________________________________________
CUSTOMER’S SIGNATURE

DATE

Public reporting burden for this collection of information is estimated to average 2 minutes per respondent. Send comments concerning this
burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Employment and Training Administration,
WIA Evaluation Room N-5641, 200 Constitution Ave. NW, Washington, DC, 20210. 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 information collection is xxxx-xxxx. Expiration Date xx/xx/20xx.

WIA Eval_App F_VSS consent form_07162012.docx