Final - Attachment B.2 STRD Consent Form Tiered Rent

TIERED RENT DEMONSTRATION

ATTACHMENT B.2- INFORMED CONSENT FORM- TIERED RENT HOUSEHOLDS

AGREEMENT TO PARTICIPATE IN THE TIERED RENT DEMONSTRATION STUDY

The U.S. Department of Housing and Urban Development, Office of Policy Development and Research (HUD) is conducting a rent reform demonstration to test different ways of setting household rent. Ten public housing agencies across the country will test an alternative rent policy. [PHA] is implementing a tiered rent policy for some households. For the tiered rent policy, the housing agency calculates a household’s Total Tenant Payment (TTP) based on income ranges. Also, the housing agency reviews the household’s income every 3 years instead of annually. Your household will be randomly assigned to either the tiered or standard rent policy through a lottery-like process.

To learn about how the tiered rent policy affects households like yours, HUD is also sponsoring a study of the tiered rent policy. MDRC, a nonprofit research organization, and its consultants (the Study Team) will conduct this study as a contractor to HUD. HUD may add other researchers to the Study Team in the future. The other researchers will comply with the protections described in this document.

This document describes the study and how information about you and your household will be used and protected. If you agree to participate, you will be asked to sign below. By signing this form, you agree to join the study. Your decision to join the study will not affect whether you will be selected to have your rent calculated under the tiered rent policy or the standard rent policy. If you decide not to join the study, it will not affect your eligibility to receive housing assistance.

A study of the tiered rent policy

The study is voluntary. If you do not join the study, there is no penalty. If you join the study, you agree to allow the Study Team to collect certain kinds of information about you and your household. The Study Team will collect information from [PHA], state or national agencies, and directly from you. The Study Team plans to collect this information from five years before today and for fifteen years after today. The Study Team will use your information to understand the effects of the tiered rent. The Study Team plans to use your information for up to twenty years after today. The Study Team will collect the following:

• Information you share as part of the study enrollment questionnaire;

• Information [PHA] collects about you and your household;

• Information about employment and earnings for you and other adult members of your household from the National Directory of New Hires records. The Study Team will use your Social Security Numbers to obtain this employment and earnings information from the U.S. Department of Health and Human Services;

• Information about your household’s receipt of one or more of the following public benefits: Food stamps/SNAP; TANF/welfare; and Medicaid or other types of publicly financed health coverage. The Study Team will use your Social Security Number to obtain this public benefits information from [relevant state or local TANF and SNAP agency] or records kept by the U.S. Department of Health and Human Services;

• Homelessness data and other data that might be useful for understanding household use of homelessness services.

• Information from local, state, and federal agencies, and government administrative databases, about your family, education, wages, and financial well-being to help answer questions about the effects of the tiered rent policy.

The Study Team may also contact you to complete one or more follow-up surveys or interviews in the future. The Study Team may use directory services, such as LexisNexis, to obtain your contact information. The Study Team will ask about your experiences with [PHA] services. They will also ask about your employment, educational attainment, household income, household composition, housing situation, financial circumstances, material hardship, and the well-being of you and your family.

The Study Team will give you a gift card to thank you for taking the time to complete a follow-up survey or interview. However, you are not required to complete any follow-up surveys and interviews. Even if you do complete one, you can skip any questions that make you uncomfortable. Language assistance services to help you complete the follow-up surveys or interviews are available upon request.

How will my information be protected?

During the study, the Study Team will maintain the confidentiality of the information it collects about you. It will keep your information in secure data storage systems. It will only use your information for research purposes and never use your name or identify you when it reports conclusions from the study. The Study Team may have to report information about you to the authorities if it learns that you or someone else may be in danger of harm.

After the study is complete, or at HUD’s request, the Study Team will securely transfer your personally identifiable information to HUD. HUD must protect your information and keep it confidential as required by the Privacy Act.¹ HUD has published a System of Records Notice that explains how HUD will use and protect your information. That Notice says that HUD intends to use your information only for research.

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

Your participation in this study will help the Study Team and the [PHA] learn whether the tiered rent policy is a better way of providing housing assistance to your household and other households like yours.

There are few risks involved. The Study Team will collect and store your personal data for many years. During the study, there is a small risk that your data could be lost, stolen, or misused, even though they take every reasonable measure to protect it.

After the study is complete, the Study Team will transfer information about you and your household to HUD. At that point, HUD will take responsibility for protecting your information and will use it as described above.

Can I stop being in the study after I agree to join?

Yes, you can withdraw from the study at any time. To do so, contact the Study Team using the contact information listed below.

If you withdraw from the study, the Study Team will not collect or use any new information from or about you. However, the Study Team may still use the information that it previously collected. If you decide to leave the study, it will not affect your eligibility for housing assistance. Leaving the study will also not affect the way the housing agency calculates your TTP. The housing agency will continue to calculate your TTP based on your group assignment.

Will my information be used for other studies?

Yes. HUD may share the data they collect with additional researchers use in their work on other studies. In addition, HUD may create a public dataset that would not contain your name or any other identifying information. That public dataset would include changes to your information to protect your identity. For example, if your age is 34, the dataset might say your age is between 30 and 35. If your income is $17,740, the dataset might say your income is between $15,000 and $20,000. These changes are supposed to ensure that no one could identify you from the public dataset.

You will not be told about or asked to give your permission for these other uses of the data. If you join this study, you agree to allow HUD to share your information for other research purposes. The data shared will not include your name or other information that could directly identify you.

Who can I call with questions about the tiered rent policy?

If you have questions at any time about the tiered rent policy, contact the [PHA] at (xxx) xxx-xxxx.

Who can I call with questions about the study?

If you have questions at any time about this study or about your rights as a research subject, you may contact the MDRC Study Team, toll-free, at (XXX) XXX-XXXX or by email at [email protected]. You may also contact HUD-PDR at [email protected].

Participant statement

I have read this document and have been given a chance to ask questions about the study. I agree to be part of this study. A copy of this consent form will be given to me.

________________________________ ____________________________

Name (Print) Signature

________________________________

Date

ADDENDUM

Paperwork Reduction Act (PRA) Statement for the Consent Form and Baseline Survey

At the time of enrollment, you will be asked to review and sign this consent form and to complete the study enrollment questionnaire. Public Reporting Burden for this information collection is estimated to average .18 hours per respondent for the consent form and .12 hours per respondent for the baseline survey, including time for reviewing the instructions and completing the questionnaire. The Stepped and Tiered Rent Demonstration Study is being conducted in 10 cities to study the impact of alternative rent policies on voucher holders’ self-sufficiency outcomes and experiences with the rent policy and the housing authorities’ experiences administering these policies. This information is being collected on families enrolled in the Stepped and Tiered Rent Demonstration Study to update their contact information and to understand their experiences at the time of their enrollment in the study. This information collection is voluntary; you are not required to respond and there are no penalties for choosing not to respond. 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.

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 8210, Washington, DC 20410–5000. When providing comments, please refer to OMB Control No. XXX. 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.

Privacy Act Statement

Authority:   Sections 501 and 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).

Purpose:  The Stepped and Tiered Rent Demonstration Evaluation Data Files will store the information that is needed to evaluate the impact of the Stepped and Tiered Rent Demonstration. Your information will be used for research purposes only.

Routine Use:  Your information may be disclosed to HUD contractors, non-federal researchers, and other entities for research purposes, or to address a data breach, as described in the Stepped and Tiered Rent Demonstration Evaluation System of Records Notice.

Disclosure:  Voluntary; you are not required to respond and there are no penalties for choosing not to respond.

SORN:  Stepped and Tiered Rent Demonstration Evaluation Data Files, PD&R/RRE.XX

1 You can learn more about how HUD will protect the information you share by reviewing the PRA Burden Statement and Privacy Act Statement on the last page of this document.

OMB Control Number: 4

Tiered Rent Study – [PHA]