Consent to Participate and Information Release Form

OMB Clearance Number: 2528-0259

Expires: XX/XX/XXXX

Family Options Study

Instrument B1-Consent to Participate—Adult Respondent

PURPOSE OF THE FAMILY OPTIONS STUDY: The Family Options Study was designed to help the Department of Housing and Urban Development (HUD) understand how different kinds of housing and services helped families who were experiencing homelessness. You and your family enrolled in the Family Options Study between September 2010 and January 2012. You may remember meeting with an interviewer while you were staying in a homeless shelter during that time. The interviewer told you about the Family Options Study and asked you to sign a participation agreement if you were interested in joining the study. This agreement explained the risks and benefits of participating in the study. The agreement also explained that researchers would contact study participants every six months or so to ask about your experiences. You also completed a survey at that time. Since that time, you may have participated in one or two additional interviews and an interviewer may have collected data from up to two children in your family.

This study is being conducted by an experienced team of researchers at Abt Associates Inc. and Abt SRBI. It is funded by the Department of Housing and Urban Development (HUD). As one of only 2,300 families enrolled in the study across 12 different sites, your continued involvement is very important to this research effort. The information gathered in this study help researchers, HUD and homeless providers better understand the challenges and barriers homeless families face. This research will also offer HUD, policy makers, and local housing and homeless providers better insight into how to help families like yours in the future.

INVITATION TO CONTINUE PARTICIPATION: As a participant in the Family Options Study, we are now inviting you to continue your participation in the study. Agreeing to continue your participation in the Family Options Study involves three things:

1. You agree to participate in a short survey now that will take about 15 minutes

2. You give permission to allow researchers to continue to contact you periodically over the next couple of years. Your continued participation means that you agree to allow researchers to contact you again in the future to ask questions about your experiences.

3. You give permission to HUD and researchers to continue to collect additional data about you and your family.

Survey. The survey will collect updated contact information for you and up to three people who always know how to reach you. The survey will also ask about your current housing, your family members, and if you are employed. Most of the questions in this survey may be familiar to you, because nearly all of them were included in the interviews you completed before. This survey interview is expected to take about 15 minutes to complete.

Periodic Contacts. In order to reach you in the future to learn more about your experiences, it is important that we have your contact information correct in our database. Over the next few years, researchers may contact you to make sure that we update your name, address, phone number, email address. We also want to collect contact information for up to three people that will always know how to reach you. We would only contact these people if we couldn’t reach you directly.

Additional data. When you agreed to participate in the Family Options Study originally, you gave permission to Family Options Study researchers to collect other information about you and your family. If you agree to continue participating in this study, it means that you agree to let Family Options Study researchers continue to get information about you from other programs. The types of information that may be collected include:

• The dates and nature of your participation in shelter, housing, or services programs

• Information about earnings from jobs from unemployment insurance wage records or other earnings data

• Information about receipt of public assistance or disability benefits

• Child welfare records—including dates in foster care etc.

• Information about new addresses from any of these sources

• School record information for your children

PARTICIPATION IS ALWAYS VOLUNTARY: Your continued participation in this study is voluntary, and as a participant, you have the right to get answers to any questions you have about the study. You also have the right to decline to answer specific questions in the survey interviews or to stop the interview entirely. If you choose not to participate in the study or refuse to answer questions in the survey there will be no penalty or loss of benefits you may receive now or in the future.

If you agree to continue to participate in this study you are not obligated to participate in future studies. You will be contacted again if the research team wants to ask you to participate in additional research activities that are not currently described in this agreement. If you choose to stop participating in this study, you can do so at any time without any penalty or loss of benefits you may receive now or in the future.

If you choose not to sign this consent form, we will not complete the interview with you at this time. You will remain part of the study sample and we will continue to collect data from other administrative records.

PROCEDURES: Once you sign this consent form, an interviewer from Abt SRBI will complete the survey with you. This survey should take about 15 minutes to complete.

At the end of the survey, the interviewer from Abt SRBI will give you a $25 gift card as a token of appreciation for your time spent completing these research activities..

POSSIBLE DISCOMFORT OR RISKS: The risks to you of continuing to participate in this study are minimal. However, there are some potential risks. Risks could include the possibility that:

• You might be uncomfortable or even upset answering some of the questions on the interviews. If you feel that way, you can choose not to answer any question on the survey. You can also stop the interview at any time.

• There is some risk that your information could be obtained by people other than the researchers doing this study. The study has strict procedures in place to protect the information you provide and to prevent this from happening. However, if that were to happen, we would contact you to let you know that this occurred.

• There is some risk that people other than the researchers doing this study or the service providers to which some treatment group members were referred could find out that you are a participant in the study. The study has strict procedures in place to prevent this from happening. However, if that were to happen, we would contact you to let you know that this occurred.

BENEFITS: There are no direct benefits to you from answering our questions. However, findings from this study will be provided to HUD and published so that homeless providers nationwide can learn more about what works best to help families experiencing homelessness.

INCENTIVES: In return for your time and effort, we will pay you $25 in the form of a gift card for participating in the 15 minute interview.

CONFIDENTIALITY: Special efforts have been taken to protect the privacy of the information you have provided us through this study. These efforts will help to ensure that any confidential information you share is not accidentally disclosed.

Only the following people will see your personal identifiers:

• The interviewer conducting this survey

• A small number of Abt and Abt SRBI research staff authorized to work on the Family Options Study, and

• Individuals involved in providing the other information we collect about you.

No one at the housing program you were referred to will see your survey responses or other information collected about you. Your answers will not affect any housing or other assistance you may receive now or in the future. Your name will never be used in any report. Your answers will be combined with the answers from other people who participate in this study. So, your answers will always be reported as part of a group. No names or individual identifying information will ever be used in any public documents.

Any information that the researchers collect about you will be kept confidential and protected to the extent allowed by the Privacy Act.¹ . This means that information about you will not be knowingly shared with others in a way that identifies you or can be associated with you, except for the instances specifically stated below or if laws make us share some of the research information that identifies you or your child.

There are three important exceptions to this promise of confidentiality. First, during the interviews, if the information you provide suggests that you intend to harm yourself or someone else, study staff may have to report this to their supervisor or other appropriate agencies. Second, if you report being the victim of abusive treatment by family members or others, or third, if you report that you have seriously harmed your (minor) child or another child in your care, study staff may have to report this to their supervisor or other appropriate agencies.

This study has a special certificate from the U.S. government. This certificate adds extra protection for the research information that identifies you. This certificate does not mean the government approves or disapproves of this study. It says that the research team does not have to identify you or provide any information about you, even if a court asks them to.

Abt Associates and Abt SRBI will maintain the confidentiality of the information from the start of the study until this follow-up has been completed and findings delivered to HUD.

QUESTIONS: If you have questions regarding this study, please contact the Abt SRBI Project Director Ms. Brenda Rodriguez at 617-386-2603. If you have questions or wish to opt out of the study, you may also contact the Abt Associates Inc. Project Director, Ms. Michelle Wood at 301-634-1777. (These are not toll-free numbers). You may also call the study toll-free line at 1-XXX-XXX-XXXX. You may also contact Ms. Anne Fletcher at the U.S. Department of Housing and Urban Development at (202) 402-4347 (not a toll-free number).

CONSENT TO PARTICIPATE: By signing this participation agreement, I confirm that I have read and understand the information presented in it. The information in this form was explained to me. I had the opportunity to ask questions. I understand that my participation is voluntary, and I can ask to be withdrawn from the study at any time. I understand that I will be given a signed copy of this consent form to keep. I voluntarily agree to continue my participation in this study of programs for homeless families.

Participant Study ID#__________________

Participant’s Name – PLEASE PRINT

Participant’s Signature Date

COMPLETE IF INTERVIEW COMPLETED BY PHONE:

Verbal Consent Obtained: YES NO

____________________________________________Name of Interviewer

____________________________________________ ________________________

Signature of Interviewer Date

OMB Disclaimer

Public reporting burden for this study averages 25minutes for each adult. This includes the time for answering the interview questions and completing the consent forms. This agency may not collect this information, and you do not have to respond to this survey, unless this form shows a currently valid OMB control number. HUD will use the information to understand how housing and services interventions affect families that experienced homelessness.

Sensitive Information

The information collected is sensitive and is protected by the Privacy Act and a Certificate of Confidentiality. This information is being collected as part of the Family Options Study. The information you give will help HUD find out what effect different housing and services have on families that experience homelessness and the long-term family safety, health, employment, education, and other outcomes. The information will be used for research purposes only. The Certificate of Confidentiality protects the data from being released for any non-research purpose. You are not required to respond to this survey and your benefits will not be affected by whether or not you respond to the survey.

IRB Clearance

Institutional Review Board

Study#: 0467
Consent Version approved: 1/27/14
Study Year:  3/19/14 - 3/18/15

This study has been reviewed by the Institutional Review Board (IRB) at Abt Associates, Inc. If you have questions about your rights on this study, contact Ms. Katie Speanburg, the IRB Administrator, at 55 Wheeler Street, Cambridge, MA 02138. Her phone number is (877)-520-6835.

1 Privacy Act Statement: HUD’s authoritative and principle purpose, conditions of uses, and impacts, if any, for not participating in the survey are referenced within the participant agreement. HUD’s statutory authority for collecting this data can be found at Section 502 (g) of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. 1701z-1; 1701z-2(d) and (g)).

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