ConnectHome Focus Groups Consent

OMB Approval No. XXX-XXXX Expires: MM-DD-YYYY

ConnectHome Focus Group Consent Form

You have been selected to participate in a research study being conducted by the United States Department of Housing and Urban Development (HUD). The purpose of this study is to understand what people in your community think about internet access at home.

If you agree to participate, here are some things you should know:

• Your participation is completely voluntary (not required), and will not affect your housing benefits in any way.

• Your name will never be used in any reports about this discussion.

• All information collected during this study will be kept private and your responses will not be identified individually in any way.

• With your permission, the discussion will be recorded. Since we are talking with a lot of people across the country, this will help us keep track of and accurately report who said what .We will not share the recording with anyone from the HUD or your local public housing office, and we will destroy the recording when the study is over.

• Your input will help the HUD understand participants’ experiences, circumstances and needs regarding in-home internet access.

• You may choose to not answer any questions. You may also leave the discussion at any time. You will not be affected in any way if you stop the discussion or decide not to answer a question.

• The discussion leader will answer any questions you have about the discussion.

• The discussion will last about 90 minutes.

• You will receive a $50 gift card at the end of the focus group as a token of appreciation.

Contact Information: The United States Department of Housing and Urban Development has authorized Insight Policy Research to conduct this study. If you have any concerns about your participation in this discussion or have any questions about the study, please contact the study director Brittany McGill at Insight Policy Research at (703) 504-9485.

Certification: By signing this document, you are certifying that you have read this agreement and that you [CHECK ONE in each line]:

____ agree/____ disagree to participate in study

____ agree/____ disagree to have the interview recorded

Name [PRINT]: _________________________Signature:_____________________ Date: _____

Insight ▪ [INSERT PRA LANGUAGE, OMB NUMBER, AND EXPIR. DATE]

Paperwork Reduction Act Notice. Public reporting burden for this collection of information is estimated to be .083 hours (5 minutes) per PHA resident, and includes time for reviewing the instructions, and completing and reviewing the responses. Your completion of this information collection is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a current, valid OMB control number.