Individual/Households Respondents

ATTACHMENT D.1

STUDY CONSENT FORM

english

OMB Control No.: 0584-0604

Expiration Date: 00/00/20xx

FOR COUNSELOR USE ONLY:

Study ID #: | | | | | | | | |

CONSENT TO PARTICIPATE

IN THE EVALUATION OF THE [STATE PROGRAM NAME] EMPLOYMENT AND TRAINING PROGRAM

The U.S. Department of Agriculture, Food and Nutrition Service is testing new ways to help participants in the [STATE SNAP NAME] Employment and Training (E&T) program. It is also doing a study to find out if these approaches can help people get a job or get a better job. A team of researchers at Mathematica Policy Research, MDRC, Kone Consulting, Insight Policy Research, and Decision Information Resources (DIR) will conduct the study.

By signing this form, you agree to take part in this important study. In this study, the following will happen:

• We will ask you to tell us about such things as your education, health, employment, and use of public assistance. We will also ask who the research team may talk to who might help them get in touch with you over the next few years (you may choose not to give this information to us).

• A computer will put you in one of [two/three] groups. This is a little like a lottery—it will be decided by chance. Each person has an equal chance of getting into one of the groups. Each group will get different kinds of services. The [two/three] groups are:

1. Expanded services group: If you are in this group, you will be able to get services such as [FILL SITE SPECIFIC INFO]

2. Regular services group: If you are in this group, you will be able to get services such as [FILLS SITE SPECIFIC INFO]

[3. No services group: (FILL SITE SPECIFIC INFO)]

• Participation is voluntary. It is up to you to decide to take part in the study, in part or in whole. If you do not want to take part, you will only be able to receive regular services but this will have no effect on your [SNAP] benefits. If you take part in the study, you have a chance to get more E&T services than you can get now. We also will learn if this new program works, and that may help you and others like you. If you do take part in the study, you do not have to answer any question – asked today or in the future – that you think is too personal.

• If you agree to take part in the study, and later you wish to leave the study, you can do so at any time by calling the study toll-free number at 1-800-xxx-xxxx. You can also leave the study by notifying [PROGRAM NAME] staff who will then notify the research team. The research team will use any information we get about you before you leave the study only for research.

Information collected as part of the study will include the following:

• During registration, we will ask you to tell us about such things as the number of people in your family including children, your race/ethnicity, and education. We will ask about employment, use of public assistance, and your health. This information is required to be part of the study. We will also ask who the research team may talk to who might help them get in touch with you over the next few years if we cannot reach you by phone. You do not have to answer the questions about any other names you have gone by or provide information on relatives or friends who may know how to contact you if we cannot reach you directly. Information you give us will be sent to Mathematica.

• Over the next few years, a person from Mathematica or DIR may ask you to take part in up to 3 telephone surveys up to 60 months after today. Each survey will take about 30 minutes. If we cannot reach you by phone, we will try to follow up with you in-person. If you refuse to take part in the survey, we will call you one last time to ask you about any concerns. Participation in these surveys is voluntary. But if you complete the first survey, you will get a $30 gift card. For the second survey, you will get a $40 gift card.

• A person from Mathematica may also ask you to do an in-person interview or be in a focus group discussion. These could take about 90 minutes. All of these activities are voluntary, but are very important for the study. You will get $50 for each interview or focus group you complete.

• Information about your earnings, and government services and benefits you receive, will be shared with the research team by Unemployment Insurance agencies, Employment Service providers, and agencies that run [STATE MEDICAID NAME], [STATE TANF NAME], and [STATE SNAP NAME]. The research team will collect this information for a period that covers up to 7 years, beginning 2 years before today and up to 5 years after today. The research team will hold this information, for study purposes only, for up to ten years.

• SNAP E&T providers and employers will give the research team information about you and about your participation in employment and training services. This includes information about the training and support services you got, the cost of the services, and information about jobs you got during and after the program.

• All information the research team gets about you will be used for research only. The information will be kept private unless the law requires otherwise. Your name will never be used in any reports and no information will be reported in any way that can identify you.

 By checking this box, I agree that I have read this consent form (or it has been read to me). I understand the information provided and voluntarily agree to participate. If I have questions, I can call the study toll-free number at 1‑800‑288-5645.

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NAME SOCIAL SECURITY NUMBER—LAST 4 DIGITS ONLY

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DATE

Public Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0604. The time required to complete this information collection is estimated to average 3 minutes, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Support, Food and Nutrition Service, USDA, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.