Appendix A Consent Form - PAIVED - REVISED

IRB # 1825

Approved on: XX/XX/2018

Valid until: XX/XX/2019

OMB Control No.:0970-0516

Expiration Date: 9/30/2019

Participant ID: ________

Interviewer Initials: _____

Consent Form

Preventing and Addressing Intimate Violence when Engaging Dads Interviews

Child Trends, an independent research organization, and their partners, Boston Medical Center and Futures Without Violence, are contracting with the Administration for Children and Families in the U.S. Department of Health and Human Services to conduct a research study to describe fatherhood programming that addresses violence that occurs between fathers and their current or former romantic partners. We are calling this intimate partner violence or IPV. We are interviewing program directors and facilitators, and staff from partnering organizations. This form has information to help you decide if you want to take part in the study.

1. PURPOSE:

We would like to ask you about your experiences providing services to fathers and families in fatherhood programs. Our goal is to better understand how fatherhood programs address IPV.

2. PROCEDURES:

If you agree, you will participate in an approximately 90-minute interview. During the interview, we will ask you about how your organization addresses IPV among fatherhood program participants. The topics covered in the interview include how you identify IPV, and programming and partnerships to prevent and address IPV.

3. RISKS AND/OR DISCOMFORTS:

Risks associated with participation include potential loss of privacy. To protect you or your organization’s privacy, your name or your organization’s name will not be used in reports without your permission and your individual responses will not be shown to anyone outside of the study team. Some questions may make you uncomfortable. If we come to a question you do not wish to answer, you can let the interviewer know and he/she will move on to the next question.

4. VOLUNTARY PARTICIPATION:

This collection of information is voluntary and will be used to better understand fatherhood programs. You can choose to stop the interview at any point. If after completing the interview you no longer wish to participate, you can let the interviewer know or you can contact Mindy Scott at 240-223-9324 to be removed from the study.

5. PRIVACY:

All information will be kept private to the extent permitted by law. The interview will be audio-recorded, if you agree to it. All recordings and written notes will be kept secure and no one outside of the study team will have access to them. Reports will describe findings in general terms and will not include identifiable information without your permission. Your organization’s participation will not affect current or future funding.

6. COSTS AND BENEFITS:

There are no costs associated with the study other than the time you spend completing the interview. You will not benefit personally from being involved in the study.

7. QUESTIONS:

If you have any comments or concerns about participating in this study, you can contact Mindy Scott, Study Director, at 240-223-9324. If you wish, you may also contact the Child Trends Institutional Review Board by calling 1-855-288-3506, by emailing [email protected] or by writing to 7315 Wisconsin Avenue Suite 1200W Bethesda, MD 20814.

8. VERBAL CONSENT:

We would like to audio record our talk so that we can make sure that we don’t miss anything you say. We will destroy all recordings within two years of completing the study. You can still be part of the study even if you do not want to be recorded. Do you agree to participate? Do you agree to be audio recorded?

NOTE: The Paperwork Reduction Act Statement: The described collection of information is voluntary and will be used to better understand the services fatherhood programs provide around intimate partner violence. Public reporting burden for the described collection is estimated to average 90 minutes, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 control number for the described collection is 0970-0516 and it expires on 09/30/2019.

Appendix A: Consent Form PAIVED Interviews
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