Appendix E. Informed Consent Form_OAHM_Final

Appendix E

OAHM Program Evaluation Informed Consent

CONSENT TO TAKE PART IN AN EVALUATION

Sponsor:	Healthy Housing Solutions
Evaluation Title:	Evaluation of HUD Older Adults Home Modifications Grant Program (“Evaluation”)
Protocol Number:	1
Healthy Housing Solutions Team Staff:	Toll-Free Number: 877-312-3046
Principal Investigator:	Amanda Reddy, 443-539-4152
Project Manager:	Noreen Beatley, 443-539-4153
Senior Research Associate:	Jill Breysse, 443-539-4155
Address:	10320 Little Patuxent Parkway, Suite 200 Columbia, MD 21044-3344 If you are hard of hearing or deaf, you may reach the above phone numbers by dialing 711 via teletype (TTY) or telecommunications device for the deaf (TDD).

OMB Control No. 2528-XXXX, expiration date XX/XX/2024. This form is designed to provide HUD with information about how effective its Older Adults Home Modification Grant Program is. The information you provide is voluntary. Your home can be enrolled in the program whether you decide to participate or not. The public reporting burden for collection of this information is estimated to be 15 minutes per response. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

Please read this form carefully. Feel free to ask me as many questions about this Evaluation as you like. I can explain words or information you do not understand. You can also call the Healthy Housing Solutions Team staff listed above to ask them questions.

Introduction

This Evaluation will collect data about a grant program developed by the U.S. Department of Housing and Urban Development (HUD) called the “Older Adults Home Modification Program” (the “program”). The program offers home modifications to help older adults be more independent and safer in their homes. HUD hired Healthy Housing Solutions to collect information about the program to evaluate its effectiveness. Healthy Housing Solutions is not part of our organization.

Because you and your home are already enrolled in the program, we are asking you to take part in this Evaluation. The purpose of this Evaluation is to help HUD learn whether the program helps reduce safety hazards and improves your ability to function in your home. Taking part in the Evaluation is entirely voluntary. Even if you can choose to not participate in the Evaluation, you will still receive the program’s home modification services.

What will happen during the Evaluation?

We will make two Evaluation visits to meet with you in your home over the next 12 to 18 months. During the first Evaluation visit, program staff will ask you questions about your physical function before home modifications are done. The second Evaluation visit will be about a year from now. During the second Evaluation visit, we will ask these questions again, to see if your ability to function in your home changed once modifications were made. During these two visits, we will also walk through your home to visually check for safety issues. Each Evaluation visit will take about 45 to 60 minutes.

In a separate phone call or visit, Evaluation staff from Healthy Housing Solutions will ask you about your experience with the program. Healthy Housing Solutions staff will not share this feedback with anyone who works for our organization.

Risks of the Evaluation

We do not anticipate you will have any adverse reactions to the program visits or the Evaluation visits. You will be asked questions about personal issues such as injuries from falls and physical health issues. These personal questions may make you uncomfortable or anxious. You do not need to answer any question that you are not comfortable answering.

If staff from our organization or Evaluation staff who visit your home see evidence of physical abuse, they may be required by law to contact an adult protective services agency. To see a list of these services in this area, go to the following National Adult Protective Services Association webpage: https://www.napsa-now.org/get-help/help-in-your-area/.

Alternatives to being in the Evaluation

You are not required to participate in this Evaluation. If you choose not to participate, you are still enrolled in the program, and you are still eligible for home modifications.

Potential benefits of being in the Evaluation

This Evaluation will help HUD learn more about whether the Older Adults Home Modification Program can help reduce health problems, especially physical issues, in homes of older adults. The Evaluation can help HUD improve the program to benefit other people across the country.

Costs of being in the Evaluation

All Older Adult Home Modification Program services and Evaluation visits will be provided at no cost to you. HUD pays these costs.

Your compensation for being in the Evaluation

You will receive no payment, gift, or other compensation for participating in the Evaluation.

Project staff payment

Our organization, Healthy Housing Solutions, and HUD are paying staff for their work in the program and this Evaluation.

Compensation for injury

There is no potential for an Evaluation-related injury because this is an observational Evaluation. You are not at increased risk of harmful environmental exposures by taking part in the Evaluation. This Evaluation cannot provide medical care to you. Call Evaluation staff listed on page 1 if you have any questions.

Protecting the privacy of your Evaluation data

Certain people and organizations will need to see, copy, and use the Evaluation data to do their part in the Evaluation. They are called ‘authorized users.’ Authorized users may see and make copies of Evaluation documents. Any Evaluation documents with your name, address, or other information that identifies you will be handled with special care to help protect your privacy. Documents containing information that may identify you may be shared with authorized users, including representatives of Healthy Housing Solutions and its subcontractor for this Evaluation.

Complete privacy of your health data cannot be promised. We will take steps to keep your answers private. Information that identifies you will be replaced with an identification code called a Study ID. The code key that identifies each client will be placed in a password-protected file to protect your privacy during the Evaluation. This code will be destroyed when all Evaluation data have been collected. Sharing your health data will be guided by professional standards and the law.

Evaluation information may be presented at meetings. These presentations will not include your name or other information that can be traced to you.

Getting answers to your questions about the Evaluation

You can ask questions about this consent form or the Evaluation at any time by contacting Evaluation staff. Their telephone numbers are listed on page 1 of this form.

Being an Evaluation volunteer

Participating in this Evaluation is voluntary. You may always say no. If you start the Evaluation, you may stop at any time. You do not need to give a reason. You will not be penalized or lose program benefits. Your part in the Evaluation may stop at any time for any reason.

You may be asked to stop participating in the Evaluation even if you do not want to stop.

New information about the Evaluation

Program staff or Evaluation staff will tell you about any new information found during the Evaluation that may affect whether you want to continue to take part.

Accessibility During the Evaluation

Your participation in this evaluation is important to us. We will continue to ensure effective communication and provide reasonable accommodations for individuals with disabilities throughout the evaluation.

Statement of consent

I have read this form. Its details were explained to me. I agree to participate in this Evaluation for the purposes listed above. I agree to provide personal information and to provide access to my home for program staff and Evaluation staff. All my questions were answered to my satisfaction. I will receive a signed and dated copy of this form for my records. I am not giving up any of my legal rights by signing this form.

______________________________________ ___/___/____

Signature of Client Date

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Printed Name of Client

Statement of person explaining consent

I have carefully explained to the client the nature and purpose of the above Evaluation. There has been an opportunity for the client to ask me questions about this Evaluation. I have answered any questions that the client has about this Evaluation.

___________________________________ ___/___/____

Signature of Person Explaining Consent Date

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Printed Name of Person Explaining Consent

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Printed Name of Organization of Person Explaining Consent