Attachment B.4 Refusal Conversion Letter

[DATE]

FIRST NAME LAST NAME

ADDRESS

CITY, STATE ZIP

Dear [FIRST NAME] [LAST NAME],

Thank you for enrolling in the Youth Transition Exploration Demonstration (YTED) about a year ago. The Social Security Administration (SSA) awarded a grant to Mathematica, an independent research company, to study YTED and conduct the survey.

I am writing to encourage you to take part in this survey.

Your input matters!

• You will receive a $50 gift card for completing the 20-minute survey. Your response is vital to the success of the study.

• Even if you did not receive services from YTED, we still need to hear from you.

• Your privacy is important. We will not share your answers in any way that reveals who you are. We will combine your answers with everyone who takes part in the survey and use them only for research.

• The survey is voluntary. You may skip any questions you do not want to answer. Your decision about the survey will not affect any benefits you receive, now or in the future.

Please call Mathematica toll-free at 1-8xx-xxx-xxxx to complete your interview or make an appointment to complete it in the future.

Have questions? Call the study team at Mathematica toll-free at 1-8xx-xxx-xxxx.

Sincerely,

Stacie Feldman

YTED Survey Director

Mathematica

Privacy Act Statement
Collection and Use of Personal Information

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 (SORN) 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 to establish or verify eligibility for Federal benefit programs 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 the survey questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is xxxx-xxxx; expiration date xx/xx/202x. We estimate that it will take about 20 minutes to read the instructions and answer the survey questions. You may send comments about our time estimate to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401

P.O. Box 2393, Princeton, NJ 08543-2393 • (609) 799-3535 phone (609) 799-0005 fax • mathematica.org

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