Appendix C. Consent Form for to Release Parent/Program Participant Contact Information - Generic

Appendix C. Consent Form to Release Parent/Program Participant Contact Information

INFORMED CONSENT FORM

Evaluation of Project Connect

A team of researchers from the Urban Institute, a nonprofit policy research organization based in Washington, DC, and its research partners the University of Chicago, Child Trends, and Chapin Hall at the University of Chicago is working with the U.S. Department of Health and Human Services, Administration for Children and Families (ACF) to see if Project Connect is working. We would like to talk to you because you receive services through this program.

PURPOSE OF THIS INTERVIEW

This interview or focus group is part of our evaluation of Project Connect. The goal of this study is to see if the program is working and to improve how the program works. We want to hear about experiences with the services you have received. We will combine what we hear from people in the interviews and focus groups and publish a public report on our findings.

TYPES OF QUESTIONS

The interview will take about an hour over the phone or through a video call [or in person if in-person data collection is allowed]. The focus group will take about an hour and a half through a video call [or in person if in-person data collection is allowed]. The interviewer will ask questions about your experiences with Project Connect and other services.

VOLUNTARY PARTICIPATION

If you sign the attached release form, the Urban Institute may contact you to give you more information about the study and schedule an interview or a focus group. By signing this form, you also give consent for your name and contact information to be taken from Project Connect administrative records and shared with the Urban Institute. We need to collect this information so that the Urban Institute can get in touch with you about participating in the interview or the focus group. When the Urban Institute contacts you, they will ask if you would like to participate in the interview or the focus group. You can say no at that point, even if you signed this form. Even if you agree to the interview or the focus group, during the interview or focus group you can refuse to answer any or all questions. Your refusal would not affect any benefits that you or your children may be receiving. You have the right to stop the interview at any time.

BENEFITS

There are no direct benefits to you from answering our questions. However, you will help us learn more about how Project Connect works and how it can be improved to help families like yours. You will receive a $50 gift card as a token of appreciation.

RISKS

There are no physical risks to you from participating in this interview. It is possible that some questions might make you uncomfortable or feel various emotions, such as sadness. If you want to talk to someone about some of the things that may have happened to you or your children, the interviewer can provide you with a list of resources. If we learn during these interviews that your life or health or the life or health of your child is in danger, we will share that information with the appropriate county or state agency. More information is provided in the Privacy section below.

PRIVACY

With your permission, the interview will be recorded to help us check our notes. The recording will be saved on a secured server and will not include your name or any other identifying information. Instead, it will be labeled with an identification number. Any information collected about you will be destroyed after the completion of the study. Your name will not be reported with any information you provide. Information you provide will be combined with answers of others and reported in a summary form. The only people that will ever have access to your individual level answers are the researchers at the Urban Institute. All the research staff at the Urban Institute are committed to privacy and have signed a Privacy Pledge. The only time this assurance of privacy does not apply is if you disclose any information about your intention to harm yourself or others, which the research team may be required to report.

Consent for release of protected client data

Please indicate if you agree to the following and sign the form.

I authorize Project Connect to give my contact information to the Urban Institute. I authorize Urban Institute to contact me for an interview as a part of this study, using the information I have provided below.

◻ Check here if you agree to share your contact information

◻ Check here if you decline to participate

Name: _____________________________________________

Signature: _________________________________________ Date: __________________________

Project Connect Staff: ________________________________________Date: __________________________

CLIENT CONTACT INFORMATION

(SECTION TO BE COMPLETED BY PROJECT CONNECT STAFF ONLY IF CLIENT CONSENTS)

Client Name			Client #
Primary Phone Number			Secondary Phone Number
Primary Email Address
Can leave voicemail?
If yes to leaving voicemail, is it ok to refer to Project Connect or something more generic like “I’m calling about your participation in a discussion”

QUESTIONS

If you have any questions about the study, you may call Michael Pergamit at the Urban Institute, 1-202-261-5276.

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 # and expiration date for the described information collection is OMB #: 0970-0XXX; expiration XX/XX/XXXX.