Attachment F_SUPPORT Act Grants_In-depth Participant Interview Consent Form_draft 2

Attachment F – In-depth Participant Interview Consent Form

OMB Control No: ____-____

Expiration Date: __/__/____

Privacy and Consent Terms

SUPPORT Act Grants:
In-Depth Interviews

You are invited to take part in an important interview study about your experiences receiving services at [NAME of SUB-GRANTEE] funded by a SUPPORT Act grant from the U.S. Department of Labor. Abt Associates, in partnership with MDRC, is conducting an evaluation of the SUPPORT Act grants for the U.S. Department of Labor. Your participation in the study will help us learn about how programs that received SUPPORT Act grants provide services to help people find employment and address substance use disorders in their communities.

We need to tell you about the interview study and what it means to be part of it. Abt Associates and MDRC are evaluating the SUPPORT Act grants. As part of the evaluation, you are invited to share your experience through a one-on-one interview with an Abt Associates or MDRC researcher.

What does it mean to be part of the interview study?

Taking part in this part of the study is completely voluntary. If you take part in the interview study, an Abt Associates or MDRC researcher will meet with you in-person to conduct an interview. The interview will last about 60 minutes. To thank you for your participation, you will receive a $20 gift card at the end of the interview.

What type of information will the study collect?

During the interview, the researcher will ask you questions about your job history; your goals and motivations for enrolling in the program; your finances; and the kinds of services you received through [NAME OF SUB-GRANTEE] to help you with your education, training, job search, and recovery process. You may consider some of these questions personal and sensitive. Because of this, the study team has taken many steps, outlined below, to protect your privacy.

Why do we need to audio-record the interview?

If you take part, we hope you will agree to audio-recording the interview. This means the interviewer can focus on listening to you and asking questions. Audio-recording the interview means we have an accurate record of what you said.

What are the risks and benefits of participating in this study?

The research team has taken careful steps to reduce the risks to you of participating in this study. Even so, you may still face some risks. These risks may include giving information that you consider to be personal and sensitive. Another risk is if someone outside of the study sees your interview information. We will make sure to take the names of people and places out of written or typed notes to protect your privacy.

Although you may not benefit directly from this study, your input will help us understand the issues faced by people like you. This allows the state and federal government to design better programs and services to help people like you achieve their career goals.

Your family, any services you may receive, including those from [NAME OF SUB-GRANTEE], and your employment will NOT be affected in any way by taking part or choosing not to take part in this interview study.

Will my information be kept private?

The research team is committed to keeping your personal information private to the extent allowed by law. However, there is a small risk of a loss of privacy. We will take strong precautions to make sure this does not happen. We will delete any information that includes your or others’ names, or names of places, when we type up the audio-recording. We will give your interview a study ID. Any piece of paper that includes your name or other identifying information will be kept in a locked storage area. Those documents and the audio recording of your interview will be destroyed after the study ends. Any computer files with your name or other identifying information will be protected by a password and stored on a secure network. Your personal information will be protected to the extent allowed by law. Our reports will combine your responses with responses from others. Any information that could identify you will be kept private and will not be in any report. We may report information from interviews in a presentation or science article.

As part of this study, you will be asked about your experiences at [NAME OF SUB-GRANTEE]. However, staff at [NAME OF SUB-GRANTEE] will not know that you are involved in this interview (unless you tell them). Anything you report about the program will not be linked to you.

There are some reasons why people other than the study team may need to see data you provided. This includes entities responsible for making sure the research is conducted safely and properly, including government offices. One such entity is the study sponsor, the U.S. Department of Labor. The U.S. Department of Labor will not see or have access to your name or address.

Data from your interview may be used by other researchers if they have permission from the U.S. Department of Labor. Any time we share your information, we will make sure that it only has your study ID number on it and nobody will know your name. Anyone who reads your interview will follow the same rules as we do to keep your information private.

Do I have to participate?

Participation in this study is voluntary. You may choose not to answer any question. You can stop the interview at any time. All you have to do is say, “I want to stop.”

This agreement is effective from the date you sign it (shown below) until the end of the U.S. Department of Labor’s research on these SUPPORT Act 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 the study director, Hannah Betesh, at [email protected] or (301) 347-5990.

You will receive a copy of this form for your records. All data collection funded by the federal government has to be approved by the Office of Management and Budget, or OMB. Data collection that is approved by OMB receives an OMB control number. An agency may not collect information unless it displays a currently valid OMB control number. A person is not required to respond to a request for information unless that number is displayed. The OMB control number for this study is XXXX–XXXX.

For questions or concerns about the research, contact the study director, Hannah Betesh, at [email protected] or (301) 347-5990. For questions or concerns about your rights as a research participant, call Teresa Doksum of the Abt Associates Institutional Review Board toll-free at 877-520-6835..

Consent to participate in this study

I have read the information in this consent form. I have discussed my questions with a member of the research staff. I voluntarily agree to participate in this interview. I have received a copy of this signed and dated consent form.

I give my permission to be audio-recorded for this interview.

Participant Name (please print):
Participant Signature:
Date:
Name of Researcher obtaining this Authorization:

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that integrate employment and substance use disorder services. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Hannah Betesh (Abt Associates); [email protected]