Attachment B_Approved non-tribal, adult lottery not required consent form

(Office Use Only -- HPOG ID Number: _________________)

Attachment B: Approved non-tribal, adult lottery not required consent form OMB Control No. 0970-0462 OMB approval expires 8/31/2018 Abt Associates IRB Approval No. 0826

AGREEMENT TO TAKE PART IN THE
HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM (HPOG) OUTCOME STUDY

FORM B: ADULT LOTTERY NOT REQUIRED (and parent permission box for minors)

You are invited to take part in an important study of healthcare training programs. The study is funded by the U.S. Department of Health and Human Services. Several research organizations – including MEF, the Urban Institute, and Insight Policy Research and other researchers – are running the study for the U.S. Department of Health and Human Services. Your taking part in the study will help us learn more about how the HPOG program helps people improve their skills, find jobs, and advance in healthcare careers.

Over the next 10 years, researchers will use information about people in the program to do the study. This form: 1) describes the HPOG Outcome study and 2) requests your participation in the study. We need to tell you about the study and what it means to be part of it.

What does it mean to be part of the Outcomes study?

We expect a total of 43,000 people at up to 27 HPOG programs across the country to participate in this study. Participation in the HPOG Outcome study is voluntary. You can choose not to be part of the study and still receive HPOG services.

The study team will collect data from all people who apply for HPOG and meet [NAME OF HPOG PROGRAM] eligibility requirements. This will happen when people first apply to the program and meet its eligibility rules.

What type of information will the study collect?

If you agree to participate in the study, researchers would like to collect the following information about you:

1. Information you provide when you first apply to the program including: current information about you, your family, your education, your income and your work history. This includes social security numbers.

2. Information you or other organizations provide to the [NAME OF HPOG PROGRAM] staff about the training and services you get while you are in the program.

3. Information from government sources so researchers can learn more about your future employment, earnings, and post-secondary education over the next few years. Abt will use your name and social security number to get some of these data from the National Directory of New Hires and the National Student Clearinghouse.

Will my information be kept private?

The research organizations conducting this study will have access to the data being collected about you. These organizations are committed to keeping your personal information private. Any researchers using information to study the program must follow strict data security procedures and sign a privacy agreement. However, there is a small risk of a loss of privacy. We will take strong precautions to make sure this does not happen. Any piece of paper that includes your name or other identifying information will be kept in a locked storage area and will be destroyed after the study ends. Any computer files with your name or other identifying information will be protected by a password and will be stored on a secure network. Your personal information will be protected to the extent allowable by law. Our reports will combine your responses with responses from others. People who read the reports will not be able to identify responses you give. Any data sets that are developed for sharing with other researchers will be stripped of information that would make it easy to identify you.

Requesting Permission

Participation in this study is voluntary. If you participate, we will ask you to disclose your social security number. Abt will use your name and social security number to get some of these data from the National Directory of New Hires and the National Student Clearinghouse. This collection is part of research activities authorized by the Patient Protection and Affordable Care Act of 2010 (H.R. 3590, Title V, Subtitle F, Sec. 5507, sec. 2008, (a)(3)(B)).

This agreement is effective from the date you sign it (shown below) until the end of HHS’s research on HPOG grants, or when you choose to withdraw permission. You may choose to withdraw your participation in the study at any time. If you do withdraw, researchers will continue to use information collected during the time you consented. To withdraw from the study, please call toll-free at 844-717-4691 (the Abt help line).

You will receive a copy of this form for your records. An agency may not conduct and a person is not required to respond to an information collection request unless it displays a currently valid OMB control number.

For questions or concerns about the research, call Abt Associates toll-free at 844-717-4691

For questions or concerns about your rights as a research participant, call Teresa Doksum at the Abt Associates Institutional Review Board at toll-free 877-520-6835.

Statement

“I have read this form and I know that my participation in the study is voluntary and I still may receive HPOG services if I choose not to participate.

• I agree to be in the research study

• I do not agree to be in the research study

PRINT YOUR NAME ABOVE

DATE

Parent or Guardian Permission Box:

For HPOG applicants under the age of 18, your parent or legal guardian also must sign below:

By signing this participation agreement, I confirm that I have read and understood the description of the HPOG Study.

• I AGREE TO LET MY CHILD _____________________________________ BE IN THE RESEARCH STUDY

CHILD NAME

• I DO NOT AGREE TO LET MY CHILD ______________________________BE IN THE RESEARCH STUDY

CHILD NAME

Print Name of Parent/Guardian

PARENT/GUARDIAN SIGNATURE date

ADD IRB STAMP

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0462. The described information collection is voluntary. If you have comments or suggestions for improving this form,, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.