Attachment B2_Tribal Evaluation Informed Consent Form A (SSNs)

(Office Use Only -- HPOG ID Number: _________________)

Attachment B2: Tribal Evaluation Informed Consent Form A (SSNs) OMB Control No. 0970-0462 OMB approval expires 07/31/2022 Abt Associates IRB Approval No. 0826

AGREEMENT TO PARTICIPATE IN THE
TRIBAL HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM (HPOG) STUDY

Tribal Evaluation Informed Consent Form A

Statement of Research

You are invited to take part in an important study of healthcare training programs. The study is funded by the U.S. Department of Health and Human Services (HHS). Several research organizations – including Abt Associates and NORC at the University of Chicago – are conducting the study for HHS.

Over the next 10 years, researchers will use information about participants in the HPOG program to do the study. This form: 1) describes the Tribal HPOG study and 2) requests your participation in the study. We need to tell you about the study and what it means to participate in it.

An explanation of the purposes of the Tribal HPOG Study

Taking part in the study will help us learn more about how the HPOG program helps people improve their skills, find jobs, and advance in healthcare careers.

The approximate number of subjects involved in the study

We expect approximately 3,000 people at up to five Tribal HPOG programs across the country to participate in this study. Participation in the Tribal HPOG study is voluntary. You can choose not to be part of the study and still receive HPOG services.

Expected duration of the subject’s participation

The study will last 10 years.

Description of the procedures to be followed

The study team will collect data from all people who apply for HPOG and meet [NAME OF HPOG PROGRAM] eligibility requirements. This will happen when people first apply to the program and meet its eligibility rules.

If you agree to participate in the study, researchers would like to collect the following information about you:

1. Information you provide when you first apply to the program including: current information about you, your family, your education, your income and your work history. This includes social security numbers.

2. Information you or other organizations provide to the [NAME OF HPOG PROGRAM] staff about the training and services you get while you are in the program.

3. Information from government sources so researchers can learn more about your future employment, earnings, and post-secondary education over the next few years. Abt and NORC will use your name and social security number to get some of these data from the National Directory of New Hires and the National Student Clearinghouse.

Identification of any procedures which are experimental

There are no experimental procedures involved.

A description of any reasonably foreseeable risks or discomforts to the subject

The risk in participating in this study include the possibility of loss of privacy. The research organizations conducting this study will have access to the data being collected about you. These organizations are committed to keeping your personal information private.

A description of any benefits to the subject or to others which may reasonably be expected from the research

While there are benefits for individuals to take part in the HPOG program, there is no direct benefit to individuals for participating in the evaluation. The evaluation is being conducted to see if and how HPOG makes a difference in people’s lives by helping them complete training and get healthcare jobs. Agreeing to participate in the HPOG evaluation will yield a societal benefit by providing information to improve workforce development programs. The findings of the HPOG evaluation overall will expand the career pathways evidence base and help build on what has been learned to date about how to design and implement successful career pathways programs and improve the outcomes of individuals who participate in these programs.

Statement describing the extent, if any, to which privacy of records identifying the subject will be maintained

The research organizations conducting this study will have access to the data being collected about you. These organizations are committed to keeping your personal information private. Any researchers using information to study the program must follow strict data security procedures and sign a privacy agreement. However, there is a small risk of a loss of privacy. We will take strong precautions to make sure this does not happen. Any piece of paper that includes your name or other identifying information will be kept in a locked storage area and will be destroyed after the study ends. Any computer files with your name or other identifying information will be protected by a password and will be stored on a secure network. Your personal information will be protected to the extent allowable by law. The research reports will combine your responses with responses from others. People who read the reports will not be able to identify responses you give. Any data sets that are developed for sharing with other researchers will be stripped of information that would make it easy to identify you.

Anticipated circumstances under which the subject's participation may be terminated by the investigator without regard to the subject's consent

Should the Department of Health and Human Services terminate this study, your participation will end.

Voluntary Involvement

Participation in this study is voluntary. You can choose not to be part of the study and still receive HPOG services.

Research, Rights or Injury

If you participate, we will ask you to disclose your social security number. Abt and NORC will use your name and social security number to get some of these data from the National Directory of New Hires and the National Student Clearinghouse. This collection is part of research activities authorized by the Patient Protection and Affordable Care Act of 2010 (H.R. 3590, Title V, Subtitle F, Sec. 5507, sec. 2008, (a)(3)(B)).

This agreement is effective from the date you sign it (shown below) until the end of HHS’s research on HPOG grants, or when you choose to withdraw permission. You may choose to withdraw your participation in the study at any time. If you do withdraw, researchers will continue to use information collected during the time you consented. To withdraw from the study, please contact Carol Hafford at NORC at the University of Chicago at 301-832-2351.You will receive a copy of this form for your records. An agency may not conduct and a person is not required to respond to an information collection request unless it displays a currently valid OMB control number.

For questions or concerns about the research, call NORC at 301-832-2351.For questions or concerns about your rights as a research participant, call Katie Speanburg at the Abt Associates Institutional Review Board at toll-free 877-520-6835.

Statement

“I have read this form and I know that my participation in the study is voluntary and I still may receive HPOG services if I choose not to participate.

• I agree to be in the research study

• I do not agree to be in the research study

PRINT YOUR NAME ABOVE

DATE

Parent or Guardian Permission Box:

For HPOG applicants under the age of 18, your parent or legal guardian also must sign below:

By signing this participation agreement, I confirm that I have read and understood the description of the Tribal HPOG Study.

• I AGREE TO LET MY CHILD _____________________________________ BE IN THE RESEARCH STUDY

CHILD NAME

• I DO NOT AGREE TO LET MY CHILD ______________________________BE IN THE RESEARCH STUDY

CHILD NAME

Print Name of Parent/Guardian

PARENT/GUARDIAN SIGNATURE date

ADD IRB STAMP

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970 0462. The described information collection is voluntary. If you have comments or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.