Attachment G Informed Consent - Revised

Supporting Statement

For the Paperwork Reduction Act of 1995: Approval for the Baseline Data Collection, Implementation Study Site Visits, and Staff Surveys for the Job Search Assistance (JSA) Strategies Evaluation

Attachment E: Informed Consent Form

OMB No. 0970-0440

November 4, 2014

Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services

Federal Project Officer

Erica Zielewski

AGREEMENT TO TAKE PART IN THE

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

JOB SEARCH ASSISTANCE (JSA) STRATEGIES EVALUATION

You are invited to take part in an important voluntary study of job search assistance services. The study is funded by the U.S. Department of Health and Human Services. It will test how well our program and alternatives work to help individuals find and keep a job. Two research organizations – Abt Associates and Mathematica Policy Research – are running the study for the U.S. Department of Health and Human Services. Your participation will help us learn more about the benefits of these programs.

Under this study, everyone will be assigned to one of [add number of groups included] different types of job search assistance. We will use a lottery to make sure that people are assigned to the groups in a fair way. Assigning people to the groups using a lottery ensures fairness. The decision about who goes to which group has nothing to do with personal traits like your age or race.

Your participation in the study is voluntary. If you decide not to participate, this will not affect your eligibility for any other benefits and services here or elsewhere. You will still participate in job search assistance activities, as required by your TANF program. You may withdraw from the study at any time without penalty. If you withdraw from the study, you may continue to receive the job search assistance services to which you were assigned.

What does it mean to be in the study?

If you agree to be in the study, we will assign you to one of [add number of groups included] groups that receive different types of job search assistance services. We will use a lottery-like procedure to determine which group you will be in. If you agree to be in the study, we will collect information from you to help understand how well the job search assistance services you receive are working. Researchers would use this information for statistical purposes only. The information will be collected regardless of which group you are placed in.

(1) The researchers will use your name, date of birth, and/or Social Security Number to collect information about you, including data maintained by this program, other schools, your employer, and government agencies. This may include information about your employment and earnings and government services you have received.

(2) The researchers may ask you to participate in a telephone survey sometime in the next year. You would receive a token of appreciation for the time you spend completing the interview. You can refuse to participate in the interviews or answer any of the questions.

Risks and Benefits of Participation

Your participation in this study will help the U.S. Department of Health and Human Services learn about the best ways to help individuals find and keep jobs. The research organizations conducting this study are committed to keeping your personal information private. However, there is a small risk of a loss of privacy. We will take strong precautions to make sure this does not happen. Any piece of paper that includes your name or other identifying information will be kept in a locked storage area and will be destroyed after the study ends. Any computer files with your name or other identifying information will be protected by a password and will be stored on a secure network. Your personal information will be protected to the extent provided by law. Our reports will combine your responses with responses from others. People who read the reports will not be able to identify responses you give.

Questions

If you have questions about this study, please contact Karin Martinson at (301) 347-5726 (toll call) or [email protected].

If you have any questions about your rights as a study participant, please contact Teresa Doksum at Abt Associates at 1-877-520-6835 (toll free).

Consent to Participate

I have read and understood the description of the U.S. Department of Health and Human Services Job Search Assistance Strategies Evaluation. I understand that I will receive one of [add number of groups included] groups that will receive different types of job search assistance. The group to which I am assigned will be picked by lottery. I know that my participation is voluntary. I understand that Abt Associates and Mathematica Policy Research are strongly committed to keeping my personal information private. My personal information will be protected to the extent provided by law. I know that I can refuse to answer any questions in the study’s interviews, or stop being in the study at any time without penalty. I understand that Abt Associates and Mathematica Policy Research will obtain information about me, as described above.

Print Name: _______________________________________________________________________

First Last

Signature: ___________________________________________________ Date: ________________

Burden Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0970-0440; this number is valid through XX/XX/XXXX. Public reporting burden for this collection of information is estimated to average 10 minutes, including the time for reviewing and signing the form.