Attachment A TANF Coaching Consent Form

Attachment A

informed consent form

Note: This informed consent form will be included in Baseline Data Collection (Attachment B). Consent will be obtained from participants prior to completion of baseline data collection.

[PROGRAM LOGO]

[PROGRAM NAME]¹

Evaluation of Employment Coaching for TANF and Related Populations

[PROGRAM NAME] IS PART OF A NATIONAL STUDY

[PROGRAM NAME] is participating in the Evaluation of Employment Coaching for TANF and Related Populations, a national study being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about whether providing people with a coach to assist them with setting and meeting goals helps them get and keep a job. The study will also help us learn whether there are ways to make the [coaching/program] work better. The U.S. Department of Health and Human Services has asked researchers from Mathematica Policy Research and its partner, Abt Associates, to assist with the study. We invite you to be a part of the study.

THE STUDY INCLUDES TWO GROUPS

All study participants will be in one of two groups: (1) those who are offered [coaching/PROGRAM NAME’s services], and (2) those who are not but are still eligible to receive [regular case management/referrals to other services in the community]. The study will compare outcomes for people in each group.

WHICH GROUP WILL I BE IN?

A computer will randomly select which group you will be in. The computer works like a flip of a coin—assignment to a group is random. This procedure makes sure that assignments to the groups are fair. Everyone who agrees to participate in the study has the same chance of being placed into either group. The chance of being able to receive [coaching/PROGRAM NAME services] is not influenced by what you say to us or your answers to the questions you will be asked when you apply. [I/NAME OF STAFF MEMBER] will let you know which group you are assigned to at the end of the application process.

WHAT HAPPENS IF I AM NOT SELECTED TO RECEIVE [COACHING/PROGRAM NAME SERVICES]?

If you are not randomly selected to [receive coaching/participate in PROGRAM NAME], you are still eligible to [receive regular case management services/a list of other services in the community].

WHAT INFORMATION WILL BE COLLECTED ABOUT ME?

If you decide to be in the study, I will ask you to answer some questions today. I will ask you questions about yourself, your family, your employment history, and your receipt of public assistance. These questions will take about 20 minutes to answer. In about [NUMBER] months and again in [NUMBER] months, the researchers will send you an invitation with a user ID and password so that you can complete a follow-up survey online, which should take about one hour. If the researchers don’t hear from you, then they will contact you by phone or in person. You will be asked about topics such as the services you received from [PROGRAM NAME] or other providers in the community, your employment, and your earnings. If you are in the program, you may also be asked to participate in other study activities, such as a two-hour in-person interview and video recording of one or more of your coaching sessions to be reviewed by members of the research team.

If you agree to be part of the study, it means you are giving permission for our program to share information with the researchers about the services you receive from the program and for our program to use information you provide for program implementation, improvement and research purposes. The researchers may use information you provide to consult directories of contact information to help them contact you about completing the follow-up surveys and verify your identity. The researchers may also contact federal and state agencies for information about your employment and earnings and your receipt of benefits from such programs as Temporary Assistance for Needy Families (TANF) and unemployment insurance. The researchers may request this information for two years before and up to 10 years after you enroll in the study.

WILL MY PRIVACY BE PROTECTED?

Everything you tell the researchers will be used for research purposes only, unless the researchers are required by law to release it for some other purpose, and except that the researchers may also share the data you provide with [PROGRAM NAME] and its data service provider for program implementation, program improvement or research purposes. All data will be kept securely. Nobody will ever publish your name in connection with the information you provide. Instead, information about you will be combined with information about other people in the study, so researchers can describe the overall program effects and participants’ experiences.

To help us protect your privacy, the researchers have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, with one exception. The Certificate of Confidentiality does not prevent the researchers from disclosing information that would identify you as a participant in the research project if you tell the interviewers anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

You should understand that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

WHAT ARE THE BENEFITS AND RISKS OF PARTICIPATING IN THE STUDY?

You may or may not benefit personally from participating in this study, but your participation in the study could help in improving services offered in the future to other people like you.

There are very minimal risks associated with participating in the study. You may feel uncomfortable answering some questions, but you can always refuse to answer those questions if you wish, and it will not change your participation in the program or the study. Although researchers will take many steps to protect all study information, there is a small risk that non-researchers could see it, including information about your employment and earnings and TANF benefits. In addition, representatives from the U.S. Department of Health and Human Services and New England Independent Review Board may inspect and have access to confidential information as they ensure your rights as a study participant are protected.

WILL I RECEIVE INCENTIVES IN APPRECIATION FOR MY PARTICIPATION?

You will not receive an incentive today, but you will receive incentives in appreciation for completing the follow-up surveys. The researchers will send you an invitation once we are ready to start a follow-up survey. The invitation will contain all the information you need to participate. For each of the two follow-up surveys you will receive a $50 gift card if you complete the survey.

IS MY PARTICIPATION VOLUNTARY?

We hope you will want to be in the study but your participation is strictly voluntary. If you participate in the study, the researchers will ask you to participate in surveys, will collect some data on you from [PROGRAM NAME] and federal and state agencies, and may ask you to participate in other data collection activities. However, you will never be required to answer questions in the survey, participate in an interview, or be videotaped. If you decide now that you do not want to participate in the study, the researchers will not collect any information about you. However, you cannot [receive coaching/participate in PROGRAM NAME] if you do not participate in the study. Either way, it will not affect your access to TANF or other public benefits.

If you agree to be in the study now, you can withdraw from the study later. However, if you withdraw from the study and were assigned to the group that [receives coaching services/participates in PROGRAM NAME], you will no longer be able to [receive coaching/participate in PROGRAM NAME]. By agreeing now to be in the study, even if later you tell us you want to withdraw from the study, you are authorizing researchers to use information that was collected about you before you withdrew. To withdraw from the study, you must call Mathematica’s help line and provide a written letter or email confirming that you no longer want to be in the study.

If you have any questions you can call Mathematica toll-free at 1-8XX-XXX-XXXX.

WHO CAN ANSWER MY QUESTIONS ABOUT THIS RESEARCH?

If you have questions, concerns, or complaints, or think this research has hurt you or made you sick, talk to the research team at the phone number(s) listed above on the first page.

This research is being overseen by an Independent Review Board (“IRB”). An IRB is a group of people who perform independent review of research studies. You may talk to them at (800) 232-9570, [email protected] if:

• You have questions, concerns, or complaints that are not being answered by the research team.

• You are not getting answers from the research team.

• You cannot reach the research team.

• You want to talk to someone else about the research.

• You have questions about your rights as a research subject.

SUBJECT’S STATEMENT OF CONSENT

I consent to take part in this research study. This study and the information in this consent form have been explained to me. I have read this consent form or it has been read to me. I have had an opportunity to ask questions and they have been answered to my satisfaction. I have been told that I have not given up any legal rights.

I voluntarily agree to take part in this research study.

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. The OMB number for the described information collection is 0970-XXXX and the expiration date is XX/XX/XXXX.

1 All fill-in brackets will be customized for each program depending on their characteristics.