Final - Family Options Study_Appendix C

Family Options Study Information Release Form OMB Clearance Number: 2528-0259

Expires: XX/XX/XXXX

Family Options Study

INFORMATION RELEASE FORM

We are very grateful for your time and cooperation in the Family Options Study. The information you have provided during the study is very useful to the Department of Housing and Urban Development (HUD), researchers and policy makers. Your information provides important information to help families like yours. HUD may want to conduct additional research about the housing and services that are part of this study—rapid rehousing, permanent subsidies, transitional housing, and the services provided by local shelters—to see how these kinds of programs could help address homelessness in the future.

Abt Associates will maintain the confidentiality of the information you provided from the start of the study until this follow-up has been completed. We would like to ask for your permission to release your personal information to HUD. You may have consented previously, but we need to ask again because the terms of that release have expired. If you give your permission Abt will transfer your personally identifiable information securely to HUD. The information we will transfer using secure methods is this:

• full name,

• current address and telephone number,

• Social Security Number, and

• your answers to the questions asked in all of the surveys including this follow-up study to HUD.

At that point, HUD will take responsibility for protecting your information and maintaining its confidentiality. Your answers will be kept separate from your name and other information that can identify you. HUD will use this information only for research. HUD will not use these data to determine your eligibility for any housing assistance or receipt of other benefits.

Part of HUD’s research may include getting information about you from Social Security, welfare, or other government agencies and local homeless providers. Examples of these agencies could include state departments of labor, local school districts, child welfare agencies, and state or other unemployment insurance agencies.

The information will be combined with your survey answers to help HUD understand how families that participated in the Family Options Study are doing now and will help HUD and its researchers learn how different kinds of housing and services helped families who were experiencing homelessness. Only HUD and members of the research team can see your records. You may still participate in this study if you do not want these records released to HUD. Again, this information will be used only for research, never to determine program eligibility.

Here are some examples of the types of information HUD and other researchers HUD funds may ask for:

• The dates and nature of your participation in shelter, housing, or services programs;

• Records of how much money you earned from your state’s department of labor or other earnings data;

• Information about receipt of public assistance or disability benefits;

• Child welfare records—including dates when children may have been in foster care;

• Information about new addresses from any of these sources;

• Your children’s school records, including information about how they scored on achievement tests, their school absences, if they repeated a grade, and how they are doing in school;

• Your and your children’s records from the criminal justice system, including motor vehicle violations or arrests for other reasons;

• Your and your children’s Medicare or Medicaid records;

• Your and your children’s participation in TANF, Food Stamps, or other social programs.

I understand that if I agree to allow HUD or other researchers to request this information about me and my children, it means:

1. I understand that HUD researchers may ask for information about me and my children from agencies like those listed above after HUD receives the data.

2. I understand that HUD may send a copy of this form to other agencies to authorize release of my and my children’s records.

3. I understand that I will sign this form only if I agree to do so. My participation is voluntary. I am NOT required to do this.

4. I understand that if I choose not to sign this form there will be no penalty or loss of benefits I may receive now or in the future.

5. I understand that even if I give permission to release my information, I can choose not to allow the release of my child’s personally identifiable information, without any penalty or loss of benefits I receive now or in the future.

6. The information from my records and my children’s records will be kept private.

7. I understand that I will not be paid for allowing records to be released to HUD.

8. I will receive a copy of this form.

9. I understand that information for my adult children (over age 18) will not be released without their consent.

HUD may also use this information to contact you in the future to see if you would like to participate in additional research. Your participation in any future research HUD or HUD-funded researchers may want to do is strictly voluntary.

If you choose not to participate in the future study, there will be no penalty or loss of benefits you may receive now or in the future. If you choose to stop participating in this study, you can do so at any time without any penalty or loss of benefits you may receive now or in the future.

Even if you give us permission to release your information, you can choose not to allow us to release your child’s personally identifiable information, without any penalty or loss of benefits you receive now or in the future.

Please look at the two items below and write your initials following the “yes” or “no” for each statement to let us know if you consent to release the identifiers to HUD for the purposes specified above. 

Yes, I consent____­­­ No, I do not consent____ to release my personal data to HUD.

Yes, I consent____ No, I do not consent____ to release my child(ren)’s personal data to HUD.
( I understand)

Abt will release data only for children who participated in the research and are still under age 18 at the time of release.)

I have read, or have read to me, the above description and I have had the chance to ask questions. By signing below or giving my verbal permission, I confirm the decision I have marked above.

/ /

Name of Participant (printed) Signature of Participant Date

COMPLETE IF INTERVIEW COMPLETED BY PHONE:

Verbal Consent Obtained: YES NO DATE:________________________

_____________________________________ __________________________________

Name of Interviewer Signature of Interviewer

Questions About Participation

If you have questions regarding the release of your personal identifiers to HUD or want to opt out of the study please contact the Abt Associates Inc. Project Director, Ms. Lauren Dunton at 301-634-1779 (this is not a toll-free number). You may also call the study toll-free line at 1-xxx-xxx-xxxx.

If you have any questions about your rights or your child’s rights as a participant in this study, you can call the Abt Institutional Review Board, toll free at (877) 520-6835.

PRA Burden Statement and Privacy Act Statement: ­­Public Reporting Burden for this information collection is estimated to average 5 minutes per respondent, including time for reviewing instructions and completing the form. The Family Options Study is a multi-site random assignment experiment designed to study the impact of various housing and services interventions for homeless families in five key domains: housing stability, family preservation, adult well-being, child well-being, and self-sufficiency. This research is conducted under the authority of the Secretary of the U.S. Department of Housing and Urban Development to undertake programs of research, studies, testing and demonstration related to the mission and programs of HUD (12 USC 1701z-1 et seq.). This information is being collected to locate the families that enrolled in the Family Options Study between September 2010 and January 2012 and to obtain consent to release personally identifiable data collected through the study to HUD. You are not required to respond. Your participation in this information collection is voluntary and you can choose not to answer any question that is asked. Your responses will not affect your current or future receipt of housing assistance or other benefits. The information requested under this collection is protected and held confidential in accordance with 5 U.S.C. § 552a (Privacy Act of 1974) and OMB Circular No. A-130. The relevant System of Records Act Notice can be reviewed at the following link: https://www.govinfo.gov/content/pkg/FR-2014-02-26/pdf/2014-04202.pdf.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to Anna P. Guido, Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street SW, Room 4176, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. 2528–0259. HUD may not conduct and sponsor, and a person is not required to respond to a collection of information unless the collection displays a valid OMB Control Number.  

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