FHEO CX Research_Consent and Demographics Form

Consent Form

Discrimination Complaints CX Research

Consent and Demographics Form Instructions

DRAFT: 03/02/22

Format:

The content and questions in this document will be included in a HUD Microsoft Form along with accompanying demographic questions. The link to the form will be sent to potential participants to verify that they consent to take part in this study. The HUD Microsoft Form will be included as a link in an email after participants sign up for a conversation. The responses will be reviewed and tracked by the CXT. Demographic questions will be voluntary and will be asked and collected in the same HUD Microsoft Form as the consent form. The form is responsive and can be viewed on a computer or smartphone.

Purpose of a consent agreement or form:

By signing a consent form, participants are saying that they have been informed about the study and consent to take part. It is best practice to send consent forms to participants prior to their scheduled conversation so that they have time to review. Informed consent should be secured from participants before the conversation or research activity begins. Consent can also be given verbally at the beginning of the interview.

• Informed: Participants understand what we are asking them to do and for what purpose and understand their rights and any potential benefits or harms due to participating.

• Consent: Participants are voluntarily giving their consent, especially if they are members of a vulnerable group. Consent can be changed or withdrawn before, during, or after a conversation.

Note: While consent is not required from federal employees, it is still always best to inform them of what they’re being asked to participate in and why.

Purpose of a demographics questionnaire:

A demographic form captures information about research participants such as age, race, ethnicity, gender, marital status, income, education, and employment. Tracking this information helps to ensure voices of impacted groups are represented, and, to hear a diverse range of perspectives. Knowing demographic information allows for another layer of data analysis. The form also helps uncover gaps in the research sample so that they can be addressed.

HUD Discrimination Complaint Process Research Consent Form

You are invited to participate in a conversation with the Department of Housing and Urban Development (HUD) to share your valuable perspectives on the housing discrimination complaint process. Use this form to learn about this research and provide consent to participate (if you choose to do so).

Research Overview

What is this project? HUD wants to make the process of reporting housing discrimination more customer-friendly, easy to navigate, transparent, and efficient. To do this, HUD is seeking to learn from those who have previously submitted a housing discrimination complaint. We hope you will consider taking part in this outreach.

What will I be asked to do? We will ask you to set aside one hour to share your experiences and perspectives about the HUD housing discrimination complaint process.

Will you record what I say? No, but we will take notes during the conversation.

What are the benefits of participating? By taking part in this conversation, you will help HUD better serve people in the future. By participating, HUD can better understand the needs of the people it serves and work to improve the discrimination complaint process.

Will I receive money or an incentive for participating? You will not receive money or an incentive for participating in this conversation.

Will this help me reopen or pursue my complaint? This process is about gathering feedback on closed complaints, and will not impact the findings, determinations, or procedural posture of those closed cases.

How will you use the information you gather from me and how will that information be shared? What you tell us will be disconnected with your identity and anonymized. We will sum up what you and others share with us into research findings that will be shared internally. We respect your privacy and will never use your name in any reports. Additionally, we will avoid including details that might make it obvious that we are talking about you.

Will you share my name? We will not use your name in any of our materials. Your name will be stored temporarily in a secure location so we can schedule a conversation with you. Only those responsible for scheduling and facilitating your conversation will have access.

Will you share other personal information about me? Yes, with your permission, we will. In any of our internal discussions or presentations, we may say “Charles (made-up name) is a man in his 30’s who lives in Texas.” We will use a made-up name to refer to you in any of our materials. With your permission, we may also share details about your experience with a government service and your perspective around it. For example, “Charles works to figure out if people are eligible for government benefits for people who’ve purchased cars that have bad tires that have been recalled.” We may share more than one detail about your experience from our conversation.

What are my rights as a participant in this conversation? Your participation is entirely voluntary. If at any time you do not feel comfortable answering a question, simply say you’d like to move to the next question. We’ll then move on to the next question. If at any time you would like to end the conversation, you may do so.

Who can I contact about this project and my participation in it? If you have questions, please reach out to Emily Moore at [email protected]. Make sure to ask your questions before completing this form.

What if I am unable to submit the consent online before our conversation? If for any reason you are unable to submit this form online, we will review the form verbally with you during our conversation and you have the option to provide verbal consent.

Consent Agreement

Consent to Use of Possible Identifying Information and Quotes
I have read the above details and have had my questions answered about taking part in this outreach effort.

* Required

I agree to take part in a conversation with representatives of HUD. *

_______(Check) Yes

_______(Check) No

I agree to my quotes and experiences being included in presentation(s) to HUD employees about this topic. I understand the name I provide will not be connected to any quotes or experiences. *

_______(Check) Yes

_______(Check) No

Please enter your full name.
This acts as your digital signature.

_______(Type Name)

Please enter today’s date.

_______(Choose Date from calendar view)

Demographics

HUD is collecting this demographic data to ensure that we speak to people from a diverse range of backgrounds.

Please select the responses that best describe you. Providing this information is voluntary and anonymous.

1. What gender do you identify as? (Check all that apply)

• Male

• Female

• Non-binary

• Transgender

• Other:_______________________

• I prefer not to say

2. What state do you live in?

• State: ____________________________

• I prefer not to say (note: not possible to add this with text box in MS Forms)

3. What is your age?

• 18-24

• 25-34

• 35-44

• 45-54

• 55-64

• 65 and above

• I prefer not to say

4. What is the highest grade or level of school you’ve completed?

• No schooling completed

• Some high school, no diploma

• High school graduate, diploma, or the equivalent (for example: GED)

• Some college credit, no degree

• Trade/technical/vocational training

• Associate degree

• Bachelor’s degree

• Master’s degree

• Doctorate degree

• I prefer not to say

5. Please specify your race/ethnicity. (Check all that apply)

• White

• Hispanic or Latino/Latina

• Black or African American

• Native American or American Indian including Native Hawaiians and Alaska Natives

• Asian / Pacific Islander

• Other: __________

• I prefer not to say

6. Do you identify with any of the following? (Check all that apply)

• I am an active service member or veteran

• I have a disability

• I identify as LGBTQ

• None of the above

• I prefer not to say

7. What is your total household income (including all federal assistance)?

• $5,000 - $25,000

• $25,000 - $45,000

• $65,000 - $85,000

• $85,000 - $105,000

• $105,000 - $125,000

• $125,000+

• I prefer not to say

8. Which best describes where you live?

• Urban/City

• Suburban/Outside a city

• Rural

• Native American tribal land

• I prefer not to say