Appendix A - Consent Materials for Fathers_updated Feb 2017

Appendix A - Consent Materials for Fathers

Agreement to Participate for Adult Fathers

Building Bridges and Bonds (B3)

You are invited to take part in the Building Bridges and Bonds study or B3 for short. A nonprofit organization called MDRC is running the study. The study is being done with Mathematica Policy Research, MEF Associates, ABT SRBI, Georgetown University, University of Cincinnati Corrections Institute, and Youth Law Center. This form describes B3 and explains what it means for you to be a part of it. When you sign this form, you agree to be in the study. Your participation is voluntary. We hope you will agree to participate.

What is Building Bridges and Bonds or B3 for short?

B3 is an important project to learn about the effects of parenting and employment services for fathers. As part of the study, [XX fatherhood program] is offering eligible fathers the chance to participate in new services at a fatherhood program. This could provide you with [INSERT EITHER the opportunity to participate in a program with your child/ new services to help you hold a job]. The goal of B3 is to learn about how to help fathers increase their employment, earnings and income and improve their family relationships.

Fathers will participate in this study from around the country. Half the fathers will be offered new services that the [XX fatherhood program] is offering. The other half will receive the usual services that [XX fatherhood program] offers. You will have the same chance of getting the new services as everyone else. Picking the fathers who will be offered the new services will be done randomly.

What does it mean to be a part of this study?

If you agree to be in B3 by signing this form, we will ask you to do the following:

• Agree to take a survey when you enroll.

• It will take about thirty minutes.

• We will ask you about you and your family. We will ask about your use of services in the community, your employment history, and child support history. [INSERT EITHER We will also ask about your relationship with your children, such as how you discipline. We will ask about your relationship with the co-parent(s) of your children./We will ask about any history you have with the criminal justice system. We will ask about your income and your relationship with your children and coparent(s).] Finally, we will ask your thoughts and opinions about how you handle various situations. You will receive a $25 gift card for completing the survey. You may refuse to answer any of the questions.

• We will ask you to tell us how we can reach you in the future. This includes the names of people who will know how to reach you.

• Agree to take a similar survey in the future, about 6 months from today.

• We will ask about the same topics in the first survey. You will receive a $35 gift card for completing the survey. You may refuse to answer any of the questions.

• Allow us to obtain information about your participation in fatherhood services.

• This will include how often you attend the program and which services you participate in.

• It may include a short set of questions we would send you by text on your phone to see how it’s going for you in the program. You will receive up to $25 in gift cards.  

• You may also be invited to participate in focus groups to hear what you think about the program. You will receive a $20 gift card if you participate in a focus group.

• Allow us to use your information to grant you access to an App designed for some fathers during the program.

  • We will not use the information you put into the App. We will look at how often you use different parts of it. You do not need to use the App if you do not want to.

• Allow us to obtain information from state and federal agencies about the services you receive.

  • This may include information about your earnings. It may also include information about any child support that you owe and pay.

  • To get this information, we will need your social security number (SSN), and child support case number if you have one. Your social security number also helps us to locate you when we want to talk to you in the future. Providing this information is voluntary.

• Allow us to contact you at some time in the future.

• If we do talk to you, you may refuse to answer any questions we ask.

• Allow us to share your information with other researchers.

• At the end of the study, we will deliver study data to the federal government. This file will not contain your name, address, date of birth, SSN, or other ID numbers that could identify you. Other researchers will then continue to learn about the services that families like yours could benefit from.

• Right now, we plan to collect information about you from before today and for up to two years after today. The study might be extended, however. If that happens, we might continue to collect your information or we might share your information with other researchers so that they can continue to collect the same kinds of information you’ve given permission for here. They would also keep your information private to the extent permitted by law.

How will my information be protected?

The study team will follow strict rules to protect your personal information. The study team is trained to protect your information. The team signs a pledge.

The study has a Certificate of Confidentiality from the U.S. government. This certificate says that we do not have to identify you, even under a court order or subpoena. However, please keep in mind: we will keep your information private to the extent permitted by law. For example, if there is concern that you or someone else may be harmed, we will have to tell the appropriate agencies to protect you and that other person. The government may see your information if it audits the study, but it would keep your information private.

The information about you will be marked with a special code number, not your name. No reports will describe you in a way that would allow you to be identified.

What are the benefits and risks of participating in the study?

Taking part in the study may help improve services for fathers.

There are some risks to being in the study. Some questions involve sensitive topics and may be stressful to answer. You do not have to answer any questions that you do not want to answer.

Any data storage has a small risk of your information being seen outside of the study team in the unlikely event of a data breach, such as a breach in computer security. However, we follow strict rules to protect your data. No reports will include your name or identifying information.

Being part of the study is your choice.

Taking part of the study is your choice. If you decide not to be in B3, there is no penalty. Your decision will not affect the fatherhood services you receive. Your decision will not affect your status with the criminal justice system or the child support enforcement system.

You can opt out of the study at any time by contacting MDRC at the email or phone number below. If you choose to drop out, the study team may still use information that was collected about you while you were in B3. You will not lose any services to which you would otherwise be entitled.

Who can I call with questions?

MDRC and Building Bridges and Bonds (B3) can be reached at [email protected] or INSERT PHONE.

Participant’s statement:

“The research procedures, risks, and benefits have been explained to me. I know I am free to ask any questions. I understand taking part in the study is my choice. I understand that taking part in the study will not affect any benefits that I or members of my family receive, now or in the future. I understand that the study will collect information about me. I know I can stop being a part of the study at any time. I know I can refuse to answer any questions during an interview. I understand my information will be kept private, to the extent permitted by law, unless there is a concern that I or someone else may be harmed. I agree to provide contact information so I can be reached in the future.”

____________________________________________________________________________________

Your Name (Print) Your Signature Date

This evaluation is being conducted on behalf of the Administration for Children and Families (ACF). 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. The OMB number for this information collection is 0970-0XXXX and the expiration date is XX/XX/XXXX.