Participant consent form

QED Study

Participant Consent form

Pathway Home Evaluation

June 2022

The OMB control number for this collection is 1290-xxxx and expires on [month/day/year]. 

According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number. Collection of this information is authorized by Section 169 of the Workforce Innovation and Opportunity Act (WIOA). The obligation to respond to this collection is voluntary. We estimate it takes about 5 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information.  Please send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Chief Evaluation Office, 200 Constitution Ave NW, Washington, DC 20210, or email [email protected] and reference OMB control number 1290-xxxx.

Participant Consent Form

Agreement to Participate in the
Pathway Home Grant Program Evaluation

You are invited to be part of the Pathway Home Grant Program Evaluation. This form explains what it means to be in the study. To join the study, sign your name at the end of the form.

What is the Pathway Home Grant Program Evaluation?

It is a study to learn how the [PROGRAM NAME] program, a Pathway Home program, helps the people it serves. The U.S. Department of Labor contracted with a third-party evaluator to conduct this study. The study will compare the differences between those that have access to Pathway Home program services and those who do not.

Who can be in the study?

Every volunteer who is eligible and appropriate for the [PROGRAM NAME] program can be in the study. Additionally, people who are not eligible for [Program Name] may be eligible if they meet some but not all of the eligibility requirements of the program.

What does it mean to be in the study?

If you choose to be in the study, the study team will collect information from you in order to learn about the differences between those who have access to Pathway Home program services and those who do not. The study team will collect information on you for up to four years.

Below is a list of data collection activities for the study:

• Background information form. Some information about your employment and criminal justice history as well as demographic and contact information. This form will also collect contact information for people who will know how to reach you for a follow-up survey. To thank you for enrolling in the study, we will provide you with a $15 gift card.

• Follow-up survey. The study team will ask you to complete a follow-up survey 12 to 15 months after your enrollment in the study. The survey will ask questions about your receipt of program services and outcomes related to employment. To thank you for your participation, we will provide you with a $25 gift card.

• Interviews and focus groups. The study team may ask to interview you about one or two years after you enroll in the study. The interview will take approximately one hour. To thank you for your participation, we will provide you with a $50 gift card. The study team may also invite you to participate in a one-hour focus group. You do not have to participate in the interview or focus group or answer any questions that make you uncomfortable.

• Program and government records. The study team will access some information about services you received from [PROGRAM NAME] records as well as information about your employment, earnings, and criminal justice involvement from government records.

How will the study use your information?

The study team will use your information for research purposes only. The team will follow strict rules to protect your privacy and keep your information private. Your name will never be used in any report written for the project. The government may see your information if it audits us.

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

You will help [PROGRAM NAME] and other programs learn how to provide better services for people like you.

The risks are small. Even if you decide not to receive [PROGRAM NAME] program services, you can still be part of the study and access other services in your community. The study team will follow strict rules to keep your data private. Personally identifying information such as Social Security Numbers will be kept private to the extent permitted by law. Furthermore, all of your Personal Identifiable Information (PII) including your name and contact information will be removed from data before we provide any results to DOL. There is a small risk of a breach of privacy; however, strong precautions will be taken to protect your information.

Do I have to be in the study?

No. The decision to be in the study is your choice. You may drop out of the study at any time by contacting the study team (see contact information below). If you drop out, the study team still may use the information collected while you were in the study.

Statement

• I have read this form and understand the information presented.

• I agree to be in the Pathway Home Grant Program Evaluation.

• I know the decision to be in the study is my choice.

• I understand I can drop out of the study at any time.

• I know that the study team will follow strict rules to protect my privacy. My name will never appear in any public document.

• I understand that the study team will get information about me. The information will come from programs and government agencies, as described above.

• I understand that the study team might contact my probation or parole officer to get current contact information so they can invite me to participate in the survey.

• I understand that I may be contacted to take part in a survey or focus group. I know I do not have to participate or answer any questions that make me uncomfortable.

___________________________________________

Applicant Date of Birth (e.g. 01/01/1995)

Name of Applicant (Please Print)

Signature of Applicant

_______________________

Date

Questions about the Pathway Home Grant Program Evaluation? Please contact a member of the Mathematica study team at [email protected] or call 1-844-990-1303. You may also contact Monica Mean at the U.S. Department of Labor (202-693-6034; [email protected]). If you have any questions about your rights as a study participant or other questions, concerns or complaints about the study, you may contact the Health Media Lab Institutional Review Board (1-202-246-8504; www.healthmedialabirb.com).

The OMB control number for this collection is 1290-xxxx and expires on [month/day/year]. 

According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number. Collection of this information is authorized by Section 169 of the Workforce Innovation and Opportunity Act (WIOA). The obligation to respond to this collection is voluntary. We estimate it takes about 5 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information.  Please send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Chief Evaluation Office, 200 Constitution Ave NW, Washington, DC 20210, or email [email protected] and reference OMB control number 1290-xxxx.