Pre-Release Focus Group Consent Form

Focus group for pre-release program participants

Participant consent form

Pathway Home Evaluation

April 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 a Group Discussion

You are invited to be part of a group discussion related to the [Program Name]. This form explains what it means to participate and also asks for you to sign the form to show that you agree to be part of the discussion.

Below is information on this group discussion:

What is the purpose of the discussion group?

The discussion group is being held to provide information for a research study on services provided under the [PROGRAM NAME]. The goal of the discussion is to learn more about the services you received and your views on and experiences with them. The services in the program are similar to those being provided in other parts of the country to help justice-involved individuals reenter the community and be successful. The services are funded under special grants (called Pathway Home grants) by the U.S. Department of Labor (DOL) which is also funding this study. The focus group is being conducted by [Mathematica/CSG/SPR] and the study overall is being conducted by a research firm (Mathematica).

What will happen in the group discussion?

The first thing you and others in the group will be asked by the group leader is to tell the group a bit about your background. Then, you and the others will be asked about how you learned about the services and why you decided to enroll, and what services you have received to date. The group will also be asked about what is working well in this program and what is not. You will have the chance to answer these questions and to talk about how this program has affected your life. You will not have to share anything you do not want to share. The group discussion will last about 60 minutes.

How will information from the focus group be used?

The study team will use your information for research purposes only. The team will follow strict rules to protect your privacy to the fullest extent allowed by law. Only members of the study team will have access to the information you provide. Your information will not be provided to the staff providing the services, the prison or jail, or the Department of Labor. Your name will never be used in any report that the team writes. You do not have to reveal your real name and may also use a pseudonym during the focus group discussion. None of the information you share in the group discussion will affect your eligibility for any services you receive through any program, nor will it affect any justice proceedings against you. After the study is over, the team will destroy the information you provide.

What are the benefits and risks of participating in the group discussion?

The benefits to participating in the group discussion include learning about others’ experiences, being able to share your own, and providing information that will help programs like [Program Name] provide better services to people like you. The risks to participating are minor but include being asked about topics that are personal and the risk that other group members may reveal information that you have said during the discussion. To limit these risks, the group leader will remind all group members that no one has to answer questions that make them uncomfortable. The group leader will also advise participants that all information shared during the discussion should be kept private and not repeated outside of this discussion.

Will participating in the group discussion affect my parole or probation?

No. Whether or not you participate in the group discussion will not affect your parole or probation in any way. What you say in the group discussion will also not affect your parole or probation in any way.

Do I have to be in the group discussion?

No. Participation is voluntary, and you do not have to participate in the group discussion. The decision to be in the group discussion is your choice. If you choose to participate, you can stop at any time. You can also choose not to answer any question in the discussion. There is no penalty for stopping or for not answering questions.

Whom do I contact if I have a question, complaint, or concern about the study?

If you have questions, concerns, or complaints about the study or you think the research has hurt you, you can contact the study team:

Ms. Samina Sattar (Pathway Home Grant Program Evaluation director from Mathematica)

1-609-945-3358

[email protected]

You may also contact the Health Media Lab Institutional Review Board if you have any questions about your rights as a study participant or other questions, concerns or complaints about the study:

Health Media Lab Institutional Review Board

1-202-753-5040

www.healthmedialabirb.com

I agree to take part in this group discussion. I have read the information above or had it read to me. A group leader explained anything I did not understand. All my questions were answered.

Printed Name

Signature Date

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.