Attachment D- FaMLE Focus Group Informed Consent

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

FOCUS GROUP PARTICIPANT CONSENT

Fatherhood and Marriage Local Evaluation and Cross-Site Data Collection

Purpose of the Study

The purpose of this research study is to learn more about Healthy Marriage and Responsible Fatherhood programs and how well they are working. We are interested in learning about how you came to be in the [HM/RF PROGRAM], what activities you have participated in, what you find helpful about the program, and what you think should be improved. You were invited to participate in this study based on your involvement in the program.

What Will Happen During the Focus Group

The focus group will include about 10 program participants plus members of the research team, and will last approximately ninety minutes. During that time, a moderator from the research team will ask you to talk about your experiences with the [HM/RF PROGRAM]. We will audio record the focus group and take notes.

Your Answers Will Be Kept Private

In order to minimize the risk of harm, all participants are asked to agree to keep the identities of all other participants private. Issues discussed in the focus group may be discussed elsewhere as long as they are discussed in a way that does not identify participants or the institutions represented. Everything you tell the research team in the focus group will be kept private. The only risk associated with participating in this focus group is the possible loss of privacy. We will guard against this by not using your name in any reports published as part of this study. Only the research team will be able to see information you provide and nothing will ever be said about you as an individual. Instead, information about you will be combined with information about everybody else in the study, so the research team can say things like “Most participants in the focus groups indicated they liked the program.” In rare circumstances, information may be released, if required by law.

Your Participation Is Voluntary

You will be included in the focus group only if you want to be. You are free to withdraw your consent and discontinue participation in this study at any time without prejudice or penalty. If you do not want to be in the focus group, it will not affect your future participation in the [HM/RF PROGRAM].

Benefits of Participating

You will receive a $25 gift card at the end of the focus group as an appreciation for participating. Some people may also find the process of sharing their experiences and ideas enjoyable.

Who to Contact with Questions

If you would like more information about this study, please contact Debra Strong at Mathematica Policy Research at [TOLL-FREE NUMBER].

Please read the following statements and fill out the appropriate section.

 Yes, I wish to participate in the study.

I understand that my responses will not be associated with me personally in any way. Data from the focus group session will be audio-recorded and transcribed. The digital audio-files will be kept by Mathematica Policy Research until [DATE], at which time they will be destroyed. The primary use of focus group transcripts will be to write reports based on focus group findings. Direct quotes from the transcript may be used in order to illustrate a point, or illuminate findings, but any names or places that could be attributable to me personally will be omitted.

I understand that I may choose not to answer specific questions asked during my focus group discussion by simply stating, “Pass” or “I prefer not to answer.” I also understand that I can request to have specific statements treated as private. I have read this form and have received a copy for my records.

Printed Name __________________________

Signature __________________________ Date ___/___/___

 No, I do not wish to participate in this study.

I have read this form and have received a copy for my records.

Printed Name __________________________

Signature __________________________ Date ___/___/___

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.

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