Final - Appendix E - Consent for Sharing Contact Information

Evaluation of the Eviction Protection Grant Program

INFORMED CONSENT AND AGREEMENT TO SHARE CONTACT INFORMATION

OMB Control # __-__

PRA Burden Statement: ­­Public Reporting Burden for this information collection is estimated to average 10 minutes. The collection is designed to provide potential study participants with sufficient information for individuals to provide informed consent to participate in a future focus group. This collection is related to the Evaluation of the Eviction Protection Grant Program.

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, REE, Department of Housing and Urban Development, 451 7th Street SW, Room 8210, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. 2528–XXXX. 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.

I, ___________________________, hereby give my permission to [insert grantee/subgrantee name] to share my contact information (e.g., name, phone number, and email) with 2M Research, a public policy research firm contracted by the U.S. Department of Housing and Urban Development (HUD) to conduct a study to learn about the implementation of the HUD Eviction Protection Grant Program. The Eviction Protection Grant Program provided a grant to [insert grantee/subgrantee name] to provide legal assistance to tenants at risk of, or subject to, eviction. I understand that 2M Research may use my phone number and email to contact me and invite me to participate in a focus group or interview to gather my perspective as a client served by [insert grantee/subgrantee name].

My consent to share my contact information is entirely voluntary and I acknowledge that I may withdraw my consent at any time. Should I have any questions or wish to withdraw my consent, I will contact Dr. Hiren Nisar ([email protected]).

Client Name, Signature, and Date:

___________________________________

Name of Client (Printed)

____________________________________

Client Email Address

_________________________________

Client Phone Number

_________________________________ _____________

Signature of Client Date

Please note that you can request to receive a copy of this consent form to keep for your records. If you require information to be presented in an accessible format, reasonable accommodations, or language assistance services to participate in this study, please contact the study’s project manager, Dr. Hiren Nisar ([email protected]), with any specific request or needs.