Consent to Participate in a Research Project

2528-XXXX

XX-XX-XXXX

CONSENT TO PARTICIPATE IN A RESEARCH PROJECT

DRAFT

Title: Youth Homelessness Demonstration Project

Principal Investigator: Debra J. Rog, Ph.D.

Sponsor: U.S. Department of Housing and Urban Development (HUD)

Invitation to Take Part and Introduction

You are invited to take part in an interview as part of a study on the service delivery system for youth who need housing and other services in [INSERT COC/CITY NAME HERE]. We are interested in finding out what services are available, how easy it is to access them, how well they meet the needs of youth who use them, and what can be done to improve the overall system.

Purpose of Research

Our goal is to understand how the system works, what services and supports are available, and what improvements need to be made. This information will be used to help improve services for youth and inform policies and programs.

Your Rights

It is important for you to know that:

• Your participation is entirely voluntary.

• You may decide not to take part or stop the interview at any time, without any changes in the services, supports, or housing you receive.

• Your answers will remain entirely confidential.

• The information requested under this collection is protected and held private in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

PROCEDURES

Public reporting burden for this collection of information is estimated to average 90 minutes per response for this Youth Focus Group. HUD may not conduct or sponsor, and a person is not required to respond to, a collection information unless that collection displays a valid OMB control number 2528-xxxx, expiring xx-xx-xxxx.

This focus group will take about one and a half hours. We will begin by asking each of you a few background questions, and then we will ask the group to share their experiences and the services and supports received and in what ways they were or were not helpful to you.

You don’t have to answer any questions you don’t like or that make you feel uncomfortable.

We would like to audio-record this session, as long as it is okay with you. The recordings are used to help us back up our notes and make sure we have all the comments that are made. If we record today’s interview, only the research staff will ever listen to the recordings. Nothing will be reported in a way that would let anyone be identified. When we report on these data, we will group them together statistically.

The information gathered during this interview will be stored securely and confidentially. There are several procedures in place to protect your personal information.

RISKS

There is a small risk that you may feel uncomfortable discussing sensitive issues and talking about unpleasant memories or “bad” experiences related to housing or homelessness. If you become upset during our meeting or after it is over, we can put you in touch with somebody to talk to.

BENEFITS

There is no direct benefit to you from being in this study. However, this information will be used to improve services for youth like yours in your community, across the state, and the country.

ALTERNATIVES

Your participation in this interview is completely voluntary. Your participation or decision not to participate will have no effect on the services you receive. If you decide to participate, you can change your mind at any time during this session or at any future point. You may also refuse to answer any questions during the interview.

COMPENSATION

You will receive a $20 gift card for your participation in this focus group.

CONFIDENTIALITY

Your privacy is important to us. All your answers will be kept confidential. No information will be shared with service providers. As we said, we will write up a summary of the group that will not use any individual names.

QUESTIONS

Before you sign this consent form, please feel free to ask any questions you may have about the study or about your rights as a research participant. If other questions come up later, you may ask Dr. Debra Rog at (301) 279-4594, the Principal Investigator. You may take as much time as needed to think this over.

CONSENT TO PARTICIPATE

I, _________________________________________________________________,

(Print your name here)

have read and understood the above statement. I consent to participate in this interview, which is being conducted by Westat to better understand how the system works, what services and supports are available, and what improvements need to be made. I acknowledge that my participation in this session is voluntary. I understand that the notes from today’s discussion will be used only by staff working on this study to accurately capture the views expressed during the discussion and my name will not appear in the summary report.

______________________________________ _________________________

Signature Date

3