Attachment J Interview Verbal Informed Consent Form

OMB#: 0970-0462

Exp Date: XX/XX/XXXX

Interview Verbal Informed Consent for Grantee and Partner Administrative Staff, Program Implementation Staff, Employers and Program Participants (completers and non-completers)

NORC Protocol/PD # 7848

CONSENT TO PARTICIPATE IN AN EVALUATION STUDY

TITLE OF STUDY: Tribal Health Profession Opportunity Grants (HPOG) 2.0 Evaluation

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Introduction:

The Administration for Children and Families (ACF), which is part of the U.S. Department of Health and Human Services, funded the Tribal Health Profession Opportunity Grants (HPOG) to provide education and training for jobs in healthcare in Tribal communities and would like to learn how these grants are working. The program you have worked with or participated in through [GRANTEE ORGANIZATION] is part of the Tribal HPOG Program.

ACF has funded an evaluation of the Tribal HPOG Program. ACF contracted with Abt Associates and their partners, including NORC at the University of Chicago (NORC), to conduct the evaluation. The tribal evaluation is under the direction of Michael Meit, MA, MPH, at NORC. NORC is a non-profit social science research organization. Other professional persons who work for NORC may assist or act for him.

An explanation of the purposes of the study

The study team will collect data through interviews and discussion groups about the Tribal HPOG program from the individuals that manage the Tribal HPOG program, Tribal HPOG program partners, Tribal HPOG program participants, and local employers in your community. Your participation in this interview will help us obtain a better understanding of who participates in Tribal HPOG, how it works, and how it can be improved. Participation in the interview is voluntary.

The expected duration of the subject's participation

We expect that your participation will last approximately (Employers, 45 minutes/Program Implementation Staff, 90 minutes/Grantee and Partner Administrative Staff; Program Completers and Program Non-completers, 60 minutes), just the length of the interview. You can stop participating at any time, and there are no consequences for you if you should stop. However, if you decide to stop, we encourage you to talk to us first.

Approximate number of subjects involved in the study

You will be one of approximately 795 people across the country participating in interviews for this study over the course of the evaluation.

Procedures to be followed

During the interview, a NORC facilitator will ask you questions about your experience with HPOG. NORC staff will take notes during the interview.

Identification of any procedures which are experimental

There are no experimental procedures involved.

Any reasonably foreseeable risks or discomforts to the subject

We may be asking you questions that are considered personal. You do not have to reveal any personal information unless you choose to do so. As in any study, there is a risk of possible loss of privacy. NORC is committed to keeping your personal information private (see the Privacy section below for additional information).

Any benefits to the subject or to others which may reasonably be expected from the research

There is no direct benefit to you for participating in the study. However, the information you provide will be helpful to design and improve approaches to health profession training programs in Tribal communities.

Privacy of records

You will not be identified in any report or publication of this study or its results. An evaluation team member will take notes during the interview. We will keep information about you private, and protect it from unauthorized disclosure, tampering, or damage. Any potentially identifying information will be kept in a secure location during the period of the study. This information will be used only for the purposes of the study and will be destroyed no later than three years after the project is over. NORC will not provide Personally Identifiable Information to ACF and will take measures to protect this information from inadvertent disclosure. Your name and any material that could identify you will remain private.

Dissemination

At the end of the evaluation study a report about the Tribal HPOG program will be prepared and submitted to ACF. The report will be shared with [GRANTEE ORGANIZATION] at a later date. It will summarize the findings, without giving names or other information that would identify you or the Tribe.

Anticipated circumstances under which the subject's participation may be terminated by the investigator without regard to the subject's consent

We do not anticipate any circumstances under which your participation will be terminated by the investigator.

Voluntary Involvement

Participation in the interview is voluntary and you can choose to not answer any questions you do not want to answer and/or can stop at any time.

Cost to Subject

There is no cost to participating in the interview.

Token of Appreciation

[Program Completers and Program Non-Completers] To thank you for your participation, you will receive a ($50 (in person interview) /$25 (telephone interview)) non-cash gift card or voucher.

Research, Rights or Injury

Your participation is voluntary, which means that you do not have to participate and you can decide not to answer any specific questions. You also may leave the interview at any point. Your participation is not required in order to continue (in your role working with the [HPOG Program]/receiving training, services or benefits from [GRANTEE] or to receive them at any point in the future).

You have the opportunity to ask, and to have answered, all your questions about this evaluation. If you have other questions, you may call Project Director Michael Meit at (301)-634-9324. You will receive a copy of this form for your records.

If you have questions about your rights as a study participant, you may call the NORC Institutional Review Board Manager, toll free, at 866-309-0542.

[Tribal Review Board if applicable]

If you have additional questions about the rights of human subjects please contact the Administrator at the [Tribal Review Board], [Contact Name], [Phone Number] [E-mail].

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Subject’s Agreement- Verbal Consent:

Do you voluntarily agree to participate in this study?