Attachment A.2 Release Form

OMB # xxxx-xxx

Expiration date: xx/xx/20xx

PERMISSION FOR OFFICE OF VOCATIONAL REHABILITATION TO RELEASE INFORMATION

TITLE OF RESEARCH STUDY: Youth Transition Exploration Demonstration

RESEARCH STUDY NUMBER: IRB protocol number

WHAT AM I BEING ASKED TO DO?

I am being asked to give permission for the Pennsylvania Office of Vocational Rehabilitation (OVR) to release my information to the Social Security Administration (SSA) and Mathematica for a research study called the Youth Transition Exploration Demonstration (YTED). I understand that giving permission for OVR to release my information is completely voluntary; I do not have to give my permission if I do not want to do so. However, I cannot participate in YTED if I do not give my permission. I am free to remove my permission later if I change my mind.

The information provided in this form may contain words I do not understand. I will ask the research study staff to explain anything I do not understand.

WHAT WILL BE DONE TO PROTECT MY INFORMATION?

Every effort will be made to maintain the privacy of my information. SSA and Mathematica will take several actions to safeguard my information in compliance with federal laws. These actions will include (but are not limited to) staff training and signed confidentiality agreements, use of appropriate technology, strict control of access to information, use of encryption (a way of preventing unauthorized viewing of information) while information is being stored or shared, and secure methods of disposing information when it is no longer needed.

CAN I CHANGE MY MIND ABOUT GIVING PERMISSION TO RELEASE MY INFORMATION?

I can change my mind at any time and remove my permission for OVR to release my information. If this happens, I must remove my permission in writing. Beginning on the date I remove my permission, OVR will not release any new information about me. However, SSA and Mathematica may continue to use any information that was released before I removed my permission.

If after signing this form, I want to remove my permission, I can contact the person below. She will make sure the written request to remove my permission is processed correctly and will inform OVR within 1 business day of receiving my request.

Karen Katz
Senior Managing Consultant
Mathematica
1100 First Street, NE, 12th Floor
Washington, DC 20002-4221

Tel. (312) 585-3352

WHAT INFORMATION ABOUT ME WILL OVR RELEASE?

OVR will release the following information about me:

Social Security number	Date of OVR application	Sex
Date of birth	Race and ethnicity	Source of referral to OVR
Whether I am a student with a disability	Date of OVR eligibility determination	Whether I am an individual with a disability
Primary disability	Secondary disability	Significance of disability
Start and end dates of trial work experience	Date of Individualized Plan for Employment (IPE)	Supported employment goal on IPE
Employment at IPE	Primary occupation at IPE	Hourly wage at IPE
Weekly hours worked at IPE	Level of primary or secondary education attained at IPE	Currently enrolled in secondary education at IPE
Currently enrolled in postsecondary education or career or technical education at IPE	Has attained a postsecondary degree, certificate, or credential at IPE	Start date of pre-employment transition services
For each service received during OVR enrollment, whether service was provided through OVR or purchased and the provider type if purchased	Measurable skill gains: Educational functional level	Measurable skill gains: Secondary
Measurable skill gains: Secondary or postsecondary transcript/report card	Measurable skill gains: Training milestone	Measurable skill gains: Skills progression
Date of OVR exit	Type of exit	Reason for exit
Employment at exit	Primary occupation at exit	Hourly wage at exit
Weekly hours worked at exit	Employment: First quarter after exit quarter	Employment: Second quarter after exit quarter
Quarterly wages: Second quarter after exit quarter	Employment: Third quarter after exit quarter	Employment: Fourth quarter after exit quarter
Retention with the same employer in the second quarter and the fourth quarter: Fourth quarter after exit quarter	VR counselor name or ID	Date of first contact with VR counselor
Frequency of contact with VR counselor	Intensive job training goal on IPE	Date of meeting with Transition Employment Team
Referral to intensive job training program	VR counselor contact with intensive job training program staff	Name or description of intensive job training program
Date of application to intensive job training program	Start date of intensive job training program	Completion date of intensive job training program
Referral to non-employment support or service provider	VR counselor contact with non-employment support or service provider staff	Name or description of non-employment support or service provider
Date of referral or application to non-employment support or service provider	Start date of non-employment support or service	Completion date of non-employment support or service
Any services provided or purchased by OVR while customer is enrolled in intensive job training program	Amount of contact VR counselor had with customer	Provided financial literacy services
Type(s) of financial literacy services provided	Referral to community partner for financial literacy services	Name or description of financial literacy service provider
Date of referral or application to financial literacy service provider	Start date of financial literacy service	Completion date of financial literacy service

OVR RELEASE FORM: YOUTH SIGNATURE PAGE

A. SIGNATURE OF YOUTH

I have read this entire form, or it has been read to me, and I understand it completely. All of my questions regarding this form have been answered to my satisfaction.

Please check () one of the following boxes and sign the form:
If you want to give OVR permission to release your information, check () this box □ YES, I agree to give OVR permission to release my information.	If you do not want to give OVR permission to release your information, check () this box □ NO, I do not give OVR permission to release my information.
Youth name: Youth signature: Date of signature: | | | / | | | / | | | | | Month Day Year

B. SIGNATURE OF PARENT OR LEGAL GUARDIAN (IF YOUTH IS YOUNGER THAN AGE 18 OR OTHERWISE CANNOT GIVE CONSENT)

I am the parent or legal guardian of the youth being asked to give permission for OVR to release information. I have read this entire form, or it has been read to me, and I understand it completely. All of my questions about this form have been answered to my satisfaction.

Please check () one of the following boxes and sign the form:
If you want to give OVR permission to release the youth’s information, check () this box □ YES, I agree to give OVR permission to release the youth’s information.	If you do not want to give OVR permission to release the youth’s information, check () this box □ NO, I do not give OVR permission to release the youth’s information.
Parent or legal guardian name: Signature: Date of signature: | | | / | | | / | | | | | Month Day Year

C. VERBAL CONSENT IF THE YOUTH LACKS UPPER LIMB FUNCTION TO COMFORTABLY WRITE

The youth, _______________________________________, is unable to sign the release form due to impaired arm function. I certify that I have carefully explained the purpose and nature of this form to them in appropriate language and they have had an opportunity to discuss it with me in detail. I have answered all of their questions and they have agreed to give OVR permission to release their information. I am signing this form to document that they have given their permission for OVR to release their information.

Signature of Research Study Representative:

Name:

Signature:

Date: | | | / | | | / | | | | |

Month Day Year

Signature of Witness 1:

Name:

Signature:

Date: | | | / | | | / | | | | |

Month Day Year

Signature of Witness 2:

Name:

Signature:

Date: | | | / | | | / | | | | |

Month Day Year

OVR RELEASE FORM: TRANSLATOR SIGNATURE PAGE

A. SIGNATURE OF READER/TRANSLATOR IF THE YOUTH OR PARENT OR GUARDIAN DOES NOT READ ENGLISH WELL

The person who has signed above, ________________________________________, does not read English well. I read English well and am fluent in (name of the language) _________________________, a language this person understands well. I have translated the entire content of this form for them. To the best of my knowledge, they understand the content of this form, have had an opportunity to ask questions regarding the form, and have had their questions answered.

Name:

Signature:

Date: | | | / | | | / | | | | |

Month Day Year

Privacy Act Statement
Collection and Use of Personal Information

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is XXXX-0XXX, expiring xx-xxx-20xx. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. You may send comments about our time estimate above to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Sections 205 and 1110 of the Social Security Act, as amended, allow the Social Security Administration (SSA) to collect this information, which SSA will use to evaluate the Youth Transition Exploration Demonstration research study. Providing this information is voluntary; not providing all or part of the information will not affect any SSA benefit. As law permits, SSA may use and share the information you submit, including with other Federal agencies, contractors, cooperative agreement awardees, and others, as outlined in the routine uses within System of Records Notices 60-0089, 60-0218, and 60-0320 available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs for Federal benefits eligibility and to recoup debts under these programs.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is XXXX-0XXX, expiring xx-xxx-20xx. We estimate that it will take about xx minutes to read the instructions, gather the facts, and answer the questions. You may send comments about our time estimate above to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

OVR Release Form Version Date: 8/22/2024 Page 4