REVISED - Informed Consent Form for Participants (Attachment H)

Attachment H – Informed Consent Form for Participants

OMB Control No: ____-____

Expiration Date: __/__/____

Building Evidence on Employment Strategies for Low-Income Families (BEES)

Agreement to take part in

You are invited to take part in a research study called Building Evidence on Employment Strategies for Low-Income Families (BEES). This form explains what it means to be part of this study. A nonprofit organization called MDRC is running the study, with funding from the U.S. Department of Health and Human Services [FOR SSA-FUNDED PROGRAMS: and the Social Security Administration] [LIST OTHER FUNDERS, AS RELEVANT]. The study team also includes Abt Associates and MEF Associates [FOR SSA-FUNDED PROGRAMS: and the Social Security Administration. Other researchers may be added in the future. By signing below, you agree to be in the BEES study.

What is BEES?

It is a study that seeks to learn about employment services. The goal of this study is to learn about how to help people get better jobs, earn more money, and improve their general well-being. [1-2 SENTENCES PROVIDING PROGRAM-SPECIFIC INFORMATION ABOUT WHAT WILL BE LEARNED FROM THE STUDY.] About 20,000 people around the country are expected to be in the study. People [FOR WHOLE FAMILY APPROACH PROGRAMS, USE: Households] in the study will be randomly assigned by a computer (like flipping a coin) to one of [NUMBER] groups:

• One group will be offered specific services, through programs like [BEES PROGRAM].

• [FOR SITES WITH MORE THAN TWO GROUPS, ADD: Another group will have access to [DESCRIPTION OF SECOND PROGRAM/SERVICES].]

• Another group will not have access to [BEES PROGRAM] [nor SECOND PROGRAM] for [LENGTH OF EMBARGO PERIOD] months, but may use other services in the community.

If you agree to be in the study, you [FOR WHOLE FAMILY APPROACH PROGRAMS, USE: your household] will have the same chance to get the services through [BEES program] [or SECOND PROGRAM] as everyone else. Your decision to join the study does not change your chance of receiving services. Getting picked for a group is not based on anything about you or your household.

What does it mean to be in the study?

By joining BEES, you agree to the following activities.

• Provide some information today. You may refuse to answer any of the questions.

• We will ask about your background, job history, and use of social services. We may ask you about your health, justice system involvement, [and alcohol and drug use.]

• We will ask how we can reach you in the future. For example, we will ask for phone numbers where we can call and text you. We will also ask for the names, addresses, emails, and phone numbers of a few people who know how to reach you.

• We will ask for your Social Security number (SSN).

• Be interviewed by phone or in person up to three times over the next two years. You may refuse to answer any of the questions.

  • [FOR 6-MONTH INTERVIEW RESPONDENTS]: This includes one follow-up interview. This will take about 15 minutes and may cover topics such as the services you received, the jobs you have had, and how things are going for you. You will receive a $15 gift card as a thank you for completing this interview.

  • [FOR 12-MONTH INTERVIEW RESPONDENTS]: This includes one follow-up interview. This will take about 30 minutes and may cover topics such as services or programs you participate in, your employment, earnings, health, and drug or alcohol use. You will receive a $25 gift card as a thank you for completing this interview.

  • A few people will be asked to do an in-person interview. If you are asked, this will take about 90 minutes and you will be asked about your experience with [BEES program]. You will receive a $50 gift card as a thank you for completing the interview.

  • Every few months we will check in so you can tell us how to best reach you. You will receive a $5 gift card after confirming or updating your contact information.

  • We may use information about you (including your SSN, if you provide it) to help us locate you when we want to talk to you in the future.

• Allow us to collect information from [BEES PROGRAM] about any services [FOR SUBSTANCE USE PROGRAMS, ADD: , including treatment for mental health or substance use disorder] you receive and how you use those services. This will include how often you use the program services and information about your program experiences from program staff.

• Allow the study team to collect information from government agencies and databases about you and the services you receive. We will use your Social Security Number (if you provide it) to obtain this information. This information will be used only for research purposes.

• As of now, we plan to collect information through 2025. If the study is extended and we do follow-up research, we may continue to collect information for an additional twenty years.

• In order to see how [BEES PROGRAM] affects your life, including your income, your benefits, [your education], [and your health], the study team might collect the following information:

• How much you earn through work. This may include information on earnings, income, and tax credits from IRS tax data or other sources.

• Information on cash assistance, food stamps, or other government benefits.

• Use of other employment programs or services in your community.

• Information about how your life is going, including household information and any child support that you owe and pay.

• [FOR SUBSTANCE USE PROGRAMS OR SSA-FUNDED PROGRAMS] Health information through [state specific Medicaid program] or other programs or agencies. This could include information on doctor visits, hospital stays, emergency room use, and prescription medications, including treatment for mental health or substance use disorder.

• [FOR SSA-FUNDED PROGRAMS] Information on disability benefits from the Social Security Administration.

• [FOR PROGRAMS TARGETING JUSTICE-INVOLVED POPULATIONS] Information about any involvement you have had with the criminal justice system.

• [FOR PROGRAMS TARGETING YOUNG ADULTS] Information on education records, including where you are or were enrolled, dates you were enrolled, and any degrees you may have completed, from the National Student Clearinghouse or other educational entities.

• [FOR WHOLE FAMILY APPROACH PROGRAMS] Information on you and other members of your household receiving housing assistance from [INSERT AGENCY NAME(S)].

• [FOR WHOLE FAMILY APPROACH PROGRAMS] School records for the children in your family. The research team will look at things like your child’s grades, attendance, special education services, and test scores.

Will other researchers use my data?

Yes. [FOR SSA FUNDED PROGRAMS] The Social Security Administration will do additional research on how [NEXTGEN BEES program] affects your earnings and receipt of disability benefits. They will do this research through 2040. They will use information such as your name, gender, date of birth, and Social Security Number to try and locate you in their records. They will only use your information to do research. The information will not be used to make decisions about any benefits you receive from the Social Security Administration, now or in the future. The Social Security Administration will not contact you directly.

Yes. We will share the data we collect from the study with other researchers to use in their work, but those records will not contain your name or other information that could identify you. You will not be asked to give your permission for this use. You are agreeing now to sharing this information for any other research purpose in the future.

Do I have to participate in the study

No. Taking part in the study is your choice. If you decide not to join, there is no penalty. Your decision will not affect any services to which you would be otherwise entitled. You will have the same chance of receiving [BEES PROGRAM SERVICES] whether you agree to be in the study or not.

You may choose to stop being in the study at any time by calling MDRC at 1-877-311-6372 or by sending an email to [email protected]. [FOR SUBSTANCE USE PROGRAMS: If you no longer want your health records collected, the study team will help you with that process.] You may refuse to answer any questions the study team asks. You do not have to give us your Social Security number to be in the study. If you choose to no longer be in the study, the study team will still use the information that was collected about you while you were enrolled in the study.

What are the benefits and risks to being in the study?

Taking part in the study might help improve services for people facing barriers to employment and [ADD PROGRAM-SPECIFIC INFORMATION HERE ABOUT THE TARGET POPULATION]. There are no direct benefits to you. There are some risks to being in the study. Some of the questions involve sensitive topics and some people may find them stressful to answer. There is a small risk that your information will be lost or misused. However, the study team follows strict rules to protect your information. No reports will include your name or other identifying information. We will keep your information private unless there is concern that you or someone else may be harmed.

[FOR WHOLE FAMILY APPROACH PROGRAMS regarding using a housing voucher: The decision to move to any new area is a big choice for any household, and you may want to carefully consider the potential benefits and risks of moving to a new area for your household and discuss these with the [BEES PROGRAM] staff.]

How will my information be protected?

The study team follows strict rules to protect your data. Any information collected for the study will be used only for research purposes. We use safety procedures like secure computers and data storage systems to protect data from being seen by anyone other than the study team. When we report findings from the research, we will never use your name or otherwise identify you. The study team may be required to report information about you to the authorities if we learn that you or someone else may be in danger of harm.

The study has [IF CERTIFICATE IS IN PROGRESS, USE INSTEAD: is applying for] a Certificate of Confidentiality from [TO BE ADDED]. This certificate says that we do not have to identify you, even under a court order or subpoena. We will use the Certificate to resist any demands for information that would identify you. [IF CERTIFICATE IS IN PROGRESS, ADD: We will contact you if the Certificate is not granted and you can decide if you want to stop being in the study.]

If you have questions at any time about the study or about your rights as a participant in the research, please call MDRC toll-free at 1-877-311-6372.

Participant’s Statement:

I understand the information contained in this document. I know participation is voluntary and I may choose to leave the study at any time. I know that I can refuse to answer any questions. I have been told that the researchers will carefully protect my information. I understand that a copy of this consent form will be given to me to keep in my records.

I agree to participate in this study. I will allow the study team to contact me using my contact information. I authorize the study team to collect information from government agencies and databases, [BEES program], other service programs, and educational entities including the National Student Clearinghouse.

Name (print): _______________________________________________________________

Name (sign): ______________________________________ Today’s date: _______________

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults. Today’s information collection will take about 15 minutes to complete. 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 and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX.

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