A. TLP Youth Consent Form - Outcomes Study - REVISED

OMB Control No: 0970-0383

Expiration Date: 09/30/2021

Young Adult Consent/Assent Form for Participation in the Youth Outcomes Study

You are invited to take part in an important study called the Youth Outcomes Study (YOS). It is a study about the experiences and outcomes of young adults who enrolled in a Transitional Living Program (TLP) or Maternity Group Home (MGH). A company called Abt Associates runs the study. The Administration for Children and Families in the U.S. Department of Health and Human Services is paying for it. This form gives information about the study and your role as a study participant. Your participation will help the research team learn more about the benefits of programs like <<Name of TLP/MGH>>. At the end of the form, you can tell us whether you want to be in the study. It is important that you read the entire form.

What does it mean to be in the study?

Being in the study is completely up to you. You get to decide if you want to be in the study or not. Even if your parent or guardian gives you permission to be in the study, you get to choose whether to be in the study or not. You can also decide to quit the study at any time. If you decide to leave the study in the future, it is okay. Leaving the study will not harm you in any way or affect your eligibility for any other services here or elsewhere.

If you agree to be in the study, the research team will collect some information about you.

1. The researchers will ask you to complete a short intake form today. You will be asked to provide your name, date of birth, Social Security Number, and other demographic information. The form will also ask you whether you or your family have received public assistance, and how the COVID-19 crisis has impacted you. You will receive a $10 electronic gift card to Amazon.com as a thank you for your time completing this form.

2. The researchers will use your name, date of birth, and/or Social Security Number for up to five years to collect data on you. This will include information about your employment and earnings from the National Directory of New Hires or similar records. It will also include information about your participation in education and training from the National Student Clearinghouse. This may include information such as course enrollment, credits earned, and completion and degrees or certificates earned.

3. The researchers will collect some information that <<Name of TLP/MGH>> collects about you. This will include verifying your Social Security Number. It will also include the dates you entered and exited the program, your exit destination, your housing status after exiting the program, and how the COVID-19 crisis impacted your TLP or MGH program services.

4. The researchers may ask you to participate in an interview or a focus group to talk about your experiences with the TLP or MGH program.

What are the possible benefits and risks if I agree to participate?

By being in the study, you will help the researchers learn more about how TLP and MGH programs help young adults with housing, education, and employment. The information learned from the study is intended to improve services for people like you.

There is very little risk for you to participate in this study. The researchers will keep your personal information private, as much as the law allows. There is a small risk of a loss of privacy. However, the researchers have many safety measures to prevent this from happening. Any computer files with your name will be stored on a secure network that is protected by a password.

Your name will never be used in any public document or data file created as part of the study. About 350 people will be in this study. When the researchers write a report, your information will be combined with information from all the other people in the study. At the end of the study, a data file with “anonymous” versions of study participants’ data may be made available to the funder of the study and authorized researchers. The data in that file will not identify you individually.

To help protect your privacy, the research team has received a Certificate of Confidentiality. The certificate is issued by the National Institutes of Health. It adds special protection to your data. It is important to understand what the Certificate can and cannot do. Because the research team has this Certificate, it can:

(1) legally refuse to give information that may identify you in any federal, state, or local proceedings. This includes if there is a court subpoena.

(2) resist any demands for information that would identify you.

Because of the Certificate, the researchers do not have to tell anyone who you are or that you are in the study.

However, even with the Certificate, the researchers may:

(1) tell state or local authorities if they find out that you or someone else could be hurt or in danger.

(2) not resist a request from the study’s funder to view the study data to audit the project or evaluate the program.

The Certificate does not prevent you or your family from telling someone about your involvement in this research. If you request in writing that you want someone to get your research information then the researchers will not withhold it.

Who should I contact if I have any questions about the study?

If you have any questions about the study, contact the researchers at 855-579-6654 (toll-free call). You can also email them at [email protected]. You can also contact Alisa Santucci, Abt Associates Study Director. You can call her at 301-347-5376 (toll call). You may also email her at [email protected]. For questions about your rights in the study, contact Katie Speanburg at Abt Associates. You can call her at 877-520-6835 (toll-free call). You may also email her at [email protected].

Consent/Assent to Participate

This agreement is effective from the date you sign it until the end of the Youth Outcomes Study. If you choose to quit the study, this agreement will end at that time. You may choose to quit the study at any time. If you do quit the study, researchers will continue to use information collected during the time before you quit. To quit the study, please call the researchers toll-free at 855-579-6654.

Consent/Assent: Here, you tell us if you agree to be in the study. Please read this carefully and ask a staff member if you have any questions about what you are agreeing to.

Please select one:

 Yes, I agree to be in the Youth Outcomes Study. I agree to allow the researchers to use my information as described above.

 No, I do not agree to be in the Youth Outcomes Study.

To confirm your selection, please enter your full legal name.

First Name: ____________________________

Middle Name (leave blank if you do not have a middle name): __________

Last Name: ____________________________

Date: __________________

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of the described voluntary collection of information is estimated to average 0.25 hours per youth response. 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.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Alisa Santucci, Abt Associates, 6130 Executive Blvd, Rockville, MD 20852; Attn: OMB-PRA 0970-0383.

TLP YOS: Young Adult Consent/Assent Form Page 1