Consent Form

NHE OPioid Evaluation – focus Group Participant Consent Form MATHEMATICA

CONSENT FORM FOR PARTICIPANT FOCUS GROUPS

Agreement to Participate in the [Grantee Project Name] Group Discussion

You are invited to be part of a [Grantee Project Name] group discussion. This form explains what it means to participate. To agree to be a part of the group discussion, sign your name at the end of the form.

Here are some questions you might have about the group discussion:

What is the group discussion for?

The group discussion is part of a U.S. Department of Labor research study called “Evaluation of the

National Health Emergency Grants to Address the Opioid Crisis.” The goal of the study is to learn how [Grantee Project Name] and similar programs work. Two organizations are running the study—Mathematica and Social Policy Research Associates.

What will happen in the group discussion?

The first thing you will be asked to do is to fill out a short form to provide us with information about your background. Then, the group will talk about what you think is working well in [Grantee Project Name] and what you think could work better. You will also have the chance to talk about how [Grantee Project Name] has affected your life. You will not have to share anything you do not want to share. The group discussion will last about 60 minutes. As a thank you for your participation in this group discussion, you will receive a $40 VISA gift card. You will receive the gift card even if you decide not to answer some questions.

How will the study use my information?

The study team will only use the information you provide on the background form and during the discussion in its research to learn how [Grantee Project Name] and similar programs work. The team will follow strict rules to protect your privacy to the fullest extent allowed by federal law. Only a few researchers will have access to this information, and all information will be stored safely and destroyed under the care of the lead researcher. Your name will never be used in any report that the team writes. None of the information you share on the background form or in the group discussion will affect your eligibility for any services you receive through any program. After the study is over, the team will destroy the information you provide.

What are the benefits and risks of participating in the group discussion?

A benefit to participating in the group discussion is that you will help [Grantee Project Name] and other programs learn how to provide better services for people like you. The risks to participating are minor but include being asked about topics that are personal and the risk that other group members may reveal information that you have said during the discussion. To limit these risks, the focus group leader will remind all group members that no one has to answer questions that make them uncomfortable and that all information shared during the discussion should be kept private.

Do I have to be in the group discussion?

No. The decision to be in the group discussion is your choice. If you choose to participate, you can stop at any time. You can also choose not to answer any question on the background form or in the discussion.

There is no penalty for stopping or for not answering questions.

Who do I contact if I have a question, complaint, or concern about the study?

[MATHEMATICA POLICY RESEARCH STAFF]

[PHONE NUMBER]

[EMAIL ADDRESS]

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

202-753-5040

https://www.healthmedialabirb.com/

I agree to take part in this discussion group. I have read the information above. A discussion group leader explained anything I did not understand. All my questions were answered.

____________________________________________________________________________

Printed Name

____________________________________________________________________________

Signature Date

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