Parent/guardian Permission Form

ATTACHMENT E: PARENT/GUARDIAN PERMISSION FORM

Evaluation of the Community Choice Demonstration

TO BE TRANSLATED: If you would like translated consent materials, or to complete the survey in a language other than English, please let the staff person you are talking to know. Please let them know if you need information to be presented in an accessible format, for example, Braille, audio, large type, or sign language interpreters. The staff person will do their best to provide a reasonable accommodation (a change or adjustment) so that you can participate.

Thank you for agreeing to participate in the [LOCAL MOBILITY PROGRAM OR Community Choice Demonstration (CCD)], sponsored by the U.S. Department of Housing and Urban Development (HUD). The [PHA] is operating the [CCD] program, with support provided by [LOCAL PROVIDER PARTNER(S)]. HUD contracted with Abt Associates and their research team to conduct the study. The research team includes Abt Associates, the Urban Institute, MEF Associates, Social Policy Research Associates, Sage Computing, a team of consultants, and other researchers that may be added in the future.

• The purpose of this study is to help HUD understand how well different types of services help families move to different neighborhoods of their choice.

• The research team is interested in the experiences of children in households who move to new neighborhoods and receive special [CCD] services compared to children in households who do not move to new neighborhoods and receive special [CCD] services.

• This form asks your permission to allow the research team and other researchers approved by HUD to collect information about your children aged 17 and under, as described more in “Housing agency information”, “Other surveys and interviews”, and “Longer-term information collection below”. Collecting information about your children may help children in other families in the future.

• This form explains the risks and benefits of participation for your children, and how the research team will protect your children’s information.

• The form also provides guidance on how to provide your permission for each of your children to participate.

The consent form you signed at the time of enrollment explained that the research team is looking to see if the children in households who move to new areas and receive the special [CCD] services do better in school, earn more money later in life, enroll in college, get a college degree, and report better health and well-being than other children their age who did not move to new areas or receive the special services. To help answer these questions, we are asking your permission to collect information about your children. You already provided some information about your children when we enrolled you into the study. We would like your permission to collect three types of additional data about your children.

1. Housing agency information: The research team will collect information from the housing authority about your children, including name, date of birth and Social Security Number (SSN). This information will be used by the research team to keep in contact with your children for follow-up surveys or interviews and access administrative data described below.

2. Other Surveys and Interviews: We might contact you in the future to collect additional information, which may be done either by the study team or other HUD-approved researchers. The long-term outcomes, especially for children, are important to the HUD and the research team, so you may be contacted during the next fifteen years to complete one or more surveys. The follow-up surveys or interviews may ask about topics such as your children’s health and schooling. Your children may also be asked to participate in future information collection efforts including interviews. These follow-up surveys or interviews will be voluntary. They do not have to participate.

3. Longer-Term Information Collection: Because we are interested in long-term outcomes, especially for children, part of the research includes getting information about your children from federal agencies, state departments of labor, local school districts, child welfare agencies, and credit bureaus. The information will be combined with the information you provide today and any future surveys to help HUD understand how families that participated in the [CCD] study are doing. This will help the research team learn how different kinds of housing and services help children. This information will only be used for research. HUD will never use these data to determine your ability to participate in different programs.

Here are some examples of the types of information the research team may collect about your children for up to 30 years:

• Records of how much money your children earned, maintained by federal agencies or your state’s department of labor;

• Information about your child’s financial well-being from databases maintained by credit bureaus (the study’s collection of this information will have no effect on your child’s credit score);

• Your children’s school records from kindergarten through high school, including information about how they scored on achievement tests, their school absences, if they repeated a grade, any disciplinary actions, how they are doing in school, and as they age out of high school data from other educational agencies about whether they enrolled in college, and whether they graduated from college;

• Information about receipt disability benefits;

• Your children’s health records, including Medicare or Medicaid;

• Your children’s records from federal government agencies, including information on employment, individual and household earnings, family composition, education, residency, neighborhood quality, and information found in tax returns; and

• Your and your children’s participation in Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) programs.

Risks, Benefits, Withdrawal from the Study, and Protecting your Children’s Information

For details of the study risks and benefits, and how to withdraw from the study, please refer to the “Agreement to Participate in the Community Choice Demonstration (CCD) Study-Head of Household Form.”

What are the benefits of being in the study?

There are no direct benefits to your children for being in the study. If you do join the study, you are helping the research team and HUD learn about ways to help households move to specific neighborhoods and whether moving to these neighborhoods improves the lives of families with children.

What are the risks of being in the study?

There is a small risk that your children’s information could be lost or mishandled, even though we take great care to protect it. There is also a small risk that if your child participates in future follow-up surveys or interviews, your child may find some of the questions to be sensitive. It is okay for them to skip those questions.

How will my child’s information be protected?

We want to assure you that all responses and personal information that you or your child provide will be kept private to the full extent provided by law. Please refer to the sections “How will my information be protected?” and “Will my information be used in the future? Can it be used for additional studies?” in the consent form that you signed for more information on how your data and your child’s data will be protected.

Do all of my children have to participate?

No, you do not have grant permission for all of your children to participate in the study. You can choose to grant permission for as many of your children to participate as you’d like. However, as explained in the consent form that you signed, in order to be eligible for the study, you must have at least one child aged 17 or under living with you. In order to be part of the study, you must grant permission for at least one of the children in your household to be part of the study. You can choose to withdraw your permission for your child to participate at any point before their 18^th birthday. Children can choose stop being part of the study themselves once they turn 18 by contacting the study team as listed below. If your child turns 18 and decides not to be in the study any longer, you and the other members of your household will still be part of the study. The research team will still use the information that was collected about your child while your child was in the study. The research team will not continue to collect information about your children after you—or your child—ask to stop being in the study. You may contact XXX XXXXX at XXX-XXX-XXXX (a toll-free number) to withdraw from the study.

Who can I call with questions?

If you have any questions about this study or about your children’s rights as a participant in the study, you may contact the research team:

• The Abt Associates Project Manager at xxx-xxx-xxxx, or by email at xxxxx @abtassoc.com.

• The study contact for HUD at xxx-xxx-xxxx, or by email at [email protected].

• The study contact for HUD at xxx-xxx-xxxx, or by email at [email protected].

If you have any questions about your rights as a participant in the study, you may contact:

• Abt Associates Institutional Review Board Administrator at xxx-xxx-xxxx, or by email at [email protected].

Please click the appropriate box next to the name of each child in the household to indicate whether or not you give your permission for that child to participate.

YES means:

Yes, I agree to have my child participate in the [CCD] study data collection, to the matching of my child’s information to the other data noted above, and to the disclosure of the student level education records (transitions from grade to grade, attendance, special education services, grades, disciplinary actions, and test scores) from any [LOCAL AREA] school until they graduate from high school or turn 18.

NO means:

No, I do not agree to have my child participate in the [CCD] study.

□ YES □ NO

Child Name Child Age

□ YES □ NO

Child Name Child Age

□ YES □ NO

Child Name Child Age

□ YES □ NO

Child Name Child Age

Once you are done indicating whether or not you give the research team permission to collect data on your children, please enter your name and date below.

Electronic Parent or Guardian Name (signature) Date

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering, and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: XXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to XX at XXXX@XXX or call at XXX-XXX-XXXX.