Participant Consent Form

Participant Consent Form

Agreement to Participate in the
Reentry Employment Opportunities (REO) Evaluation

You are invited to be part of the Reentry Employment Opportunities (REO) Evaluation. This form explains what it means to be in the study. To join the study, sign your name at the end of the form.

What is the REO Evaluation?

It is a study to learn how the [INSERT PROGRAM NAME] program helps the people it serves. The U.S. Department of Labor contracted with a third-part evaluator to conduct this study.

Who can be in the study?

Every volunteer who is eligible and appropriate for the [INSERT PROGRAM NAME] program can be in the study.

What does it mean to be in the study?

You have a chance to get into the [INSERT PROGRAM NAME] program. [INSERT PROGRAM NAME] does not have enough funding to help everyone who may want services. Therefore, participants will be chosen at random to get invited to receive services from the [INSERT PROGRAM NAME] program. The selection is like a lottery; it has nothing to do with your age, race, gender, criminal history, or anything else about you. If you are selected in the lottery, you will be invited to receive services. If you do not get an invitation, you will not be able to be in the [INSERT PROGRAM NAME] program for 2 years. However, you will continue to be part of the study and you will be given a list of other services in the community that may be helpful. The study team will collect information on you for up to four years.

• Background information. Some information about your employment and criminal justice history as well as demographic and contact information.

• Interviews. Some information will come from you. The study team may ask to interview you about one or two years after you enroll in the study. The interview will take approximately 30 minutes. To thank you for your participation, we will provide you with a $25 gift card. You do not have to do the interview or answer any questions that make you uncomfortable.

• Program and government records. Other information will come from records about you. These records may include information from [INSERT PROGRAM NAME] about your program activities. They may also include information at local, state and federal agencies about your employment and earnings and information from the juvenile and adult criminal justice systems.

How will the study use your information?

The study team will use your information for research purposes only. The team will follow strict rules to protect your privacy. Your information will be kept private. Your name will never be used in any report written for the project. Also, the study team will have to report your information if you tell us that you or someone else is in danger. The government may see your information if it audits us, but it, too, will protect your privacy.

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

You will help [INSERT PROGRAM NAME] and other programs learn how to provide better services for people like you.

The risks are small. Even if you are not selected for the [INSERT PROGRAM NAME] program, you will still be part of the study and will have access to other services in your community. The study team will follow strict rules to keep your data private. There is a small risk of a breach of privacy; however, strong precautions will be taken to protect your information.

Do I have to be in the study?

No. The decision to be in the study is your choice. However, only people who are in the study will have a chance to be in the [INSERT PROGRAM NAME] program. You may drop out of the study at any time by contacting Mathematica (see below). If you drop out, the study team still may use the information collected while you were in the study.

Statement

• I have read this form and understand the information presented.

• I agree to be in the REO Evaluation.

• I know the decision to be in the study is my choice.

• I know that I will have a chance to be in the [INSERT PROGRAM NAME] program. If I am not selected, I will not be able to be in the program for 2 years.

• I understand I can drop out of the study at any time.

• I know that the study team will follow strict rules to protect my privacy. My name will never appear in any public document.

• I understand that the study team will get information about me. The information will come from programs and agencies, as described above.

• I understand that I may be contacted to take part in a survey. I know I do not have to answer any questions that make me uncomfortable.

___________________________________________

Applicant Date of Birth (e.g. 01/01/1995)

Name of Applicant (Please Print)

Signature of Applicant

_______________________

Date

Questions about the REO Evaluation? Please contact Jillian Stein from Mathematica at [STUDY EMAIL ADDRESS] or call 1-888-XXX-XXXX. You may also contact the Health Media Lab Institutional Review Board if you have any questions about your rights as a study participant or other questions, concerns or complaints about the study: Health Media Lab Institutional Review Board; 1-202-753-5040; www.healthmedialabirb.com