Baseline Consent Forms

Transition WORKS Voluntary Participation Consent
I understand that:
•

I have been asked to be in a research study because I get benefits from Social Security. The
study is called Transition WORKS.

•

The purpose of the study is to learn how youth with disabilities can improve their educational
and employment outcomes and become more independent adults.

•

The information may help others in the future. The study may or may not make it easier for me
to become independent. Up to 800 youth in Erie County will be in the study.

•

Mathematica Policy Research, Inc. (MPR) is doing the study.
Administration (SSA) is paying for the study.

•

There is no cost to me to be in the study.

•

I answered questions on the telephone on [DATE]. If I agree to be in the study, the
researchers may use my answers. If I do not want to be in the study, the researchers will
destroy my answers. If I decide not to be in the study, nothing will happen to the benefits I get
now.

•

The Social Security

All the answers that I gave on [DATE] or give in the future will:
(1) be kept confidential. Confidential means that the data will be kept as private as possible.
MPR, Transition WORKS, and Social Security will share the information they collect about
me with each other to evaluate the program and to help me transition into adult life and be
as self sufficient as I can be.
(2) be protected by the Privacy Act. Information about the Privacy Act is at the end of this
form.
(3) be used for research purposes. I still have to report my earnings directly to SSA just as if
I were not part of the study. This is so SSA can determine my benefits.

•

If I agree to be in the study, these things will happen:
(1) I will have a chance to take part in Transition WORKS. This 24-month program includes:
• Exploring career, educational, and social opportunities
• Helping me find and keep a job that matches my abilities and goals in life
• Helping me continue my education after high school
• Benefits counseling for me and my parents
• Organizational training for me and my parents

Research and Treatment Consent Template – 6-28-06

Page 1

(2) MPR will randomly select youth to see who gets to participate in Transition WORKS.
Selecting randomly is like a lottery or tossing a coin. It is a fair way to make sure that
everyone who wants to has a fair chance of participating.
(3) If I am selected and enroll in Transition WORKS, I will also be able to use special waiver
rules. These rules are listed at the end of this form.
(4) MPR will ask me to answer questionnaires two more times—one year from now, and
three years from now. Even if I agree to be in the study today, I do not have to answer
questions in the future.
(5) MPR will send me a $10 Target gift card to say “thank you” every time I answer their
questions in the future. This money will not change the benefits I receive from Social
Security.
(6) If I am selected to participate in Transition WORKS, from time to time staff will ask me or
my parents questions about my experience or observe me or my parents to evaluate the
program.
(7) The researchers will look at records they get from Social Security and other places such
as my school, Unemployment Insurance, Food Stamps, and TANF. They may look at
records through 2010.
•

I do not have to take part in this project and there is no penalty for dropping out whenever I
choose.

•

If I have any questions about this study, I can call Karen CyBulski at MPR. Her number is
609-936-2797 or 800-951-7357. If I am deaf or hard of hearing, I can call 877-542-6734
(TTY).

•

I can keep a blank copy of this form.

About the Privacy Act:
The Social Security Administration is allowed to collect the information asked for while you
participate in the Youth Transition Demonstration Project under section 1110 of the Social
Security Act. We use the information to decide what services would best help you. You do not
have to give us this information. However, if you do not, we will be unable to offer you services.
There are certain situations authorized by Federal law in which Social Security may release the
information you give us through this project. For example, we will release the information to a
congressional office in response to an inquiry that office may make at your request or to an
evaluation contractor hired by Social Security to evaluate the project.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this, contact
any Social Security Office.

Research and Treatment Consent Template – 6-28-06

Page 2

YTDP Waivers from SSA:
•

If I receive benefits from Social Security and a continuing disability review or age-18 medical
redetermination finds that I am no longer entitled to benefits, Social Security will continue to
pay benefits to me.

•

If I receive benefits from Social Security or become eligible for such benefits while
participating in the Youth Transition Demonstration Project, Social Security also will apply
the following special rules in determining my eligibility and benefit amount:
- In determining Supplemental Security Income (SSI) eligibility and payment
amount, Social Security will apply the student earned income exclusion to
earnings regardless of my age.
- In determining SSI eligibility and payment amount, Social Security will disregard
the first $65 plus three-fourths (instead of one-half) of any earnings over $65 if
those earnings are not covered by the student earned income exclusion.
- Social Security will apply the SSI rules for individual development accounts
(IDAs) that involve Federal funds to IDAs that do not involve Federal funds. That
is, any earnings I deposit to the account will not count as income, matching
deposits will not count as income, and the IDA will not count toward the SSI
resources limit.
- Ordinarily, a plan for achieving self-support (PASS) must specify an occupational
goal at the outset. For participants in the Youth Transition Demonstration Project,
Social Security will approve an otherwise satisfactory PASS that specifies either
career exploration or post-secondary education as its goal. If the goal is postsecondary education, an occupational goal must be specified at least one year
before completion of course requirements.

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.
We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating
to our time estimate to this address, not the completed form. The valid OMB control number for this information collection is
0960-0687.

Research and Treatment Consent Template – 6-28-06

Page 3

SIGNATURE PAGE
YOUTH
Please check (!) one of the following boxes and sign the form:
IF YOU WANT TO BE IN THE
STUDY, CHECK (!) THIS BOX

IF YOU DON’T WANT TO BE IN THE
STUDY, CHECK (!) THIS BOX

" YES, I agree to be in the Transition

" NO, I do not want to be in the Transition

WORKS study.

WORKS study.

Sign your name here:
Print your name here:
Write your Social Security Number in the boxes: |

|

|

|-|

|

|-|

|

|

|

|

PARENT OR GUARDIAN
Please check (!) one of the following boxes and sign the form:
IF YOU WANT YOUR YOUTH TO
BE IN THE STUDY, CHECK (!)
THIS BOX

" YES, I agree that [NAME] may be in the

IF YOU DO NOT WANT YOUR
YOUTH TO BE IN THE STUDY,
CHECK (!) THIS BOX

" NO, [NAME] may NOT be in the

Transition WORKS study.

Transition WORKS study.

Sign your name here:
Print your name here:
NOTE: WE DO NOT INCLUDE THIS BOX FOR YOUTH WITHOUT LEGAL GUARDIANS.
Please place this form in the enclosed pre-paid envelope and mail it to:
Youth Transition Demonstration Project
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543

Research and Treatment Consent Template – 6-28-06

Page 4

Youth Transition Demonstration Project Voluntary Participation Assent/Consent

I understand that:
•

I have been asked to be in a research study because I get benefits from Social Security. The
study is called The Youth Transition Demonstration Project.

•

The purpose of the study is to learn how youth with disabilities can improve their educational
and employment outcomes.

•

The information may help others in the future. The study may or may not make it easier for me
to become independent. Up to 800 Bronx youth will be in the study.

•

Two groups are doing the study: Mathematica Policy Research, Inc. (MPR) and City University
of New York (CUNY). The Social Security Administration (SSA) is paying for the study.

•

There is no cost to me to be in the study.

•

I answered questions on the telephone on [DATE]. If I agree to be in the study, the
researchers may use my answers. If I do not want to be in the study, the researchers will
destroy my answers. If I decide not to be in the study, nothing will happen to the benefits I get
now.

•

All the answers that I gave on [DATE] or give in the future will:
(1) be kept confidential. Confidential means that the data will be kept as private as possible.
MPR, CUNY, and Social Security will share the information they collect about me with
each other to evaluate the program and to help me transition into adult life and be as self
sufficient as I can be.
(2) be protected by the Privacy Act. Information about the Privacy Act is at the end of this
form.
(3) be used for research purposes. I still have to report my earnings directly to SSA just as if
I were not part of the study. This is so SSA can determine my benefits.

Research and Treatment Consent Template – 6-28-06

Page 1

•

If I agree to be in the study, these things will happen:
(1) I will have a chance to take part in CUNY’s Youth Transition Demonstration Project
(YTDP). This 20-month program includes:
• Saturday activities at one of the CUNY colleges in the Bronx, including recreation
classes and job classes for me, and information and support classes for my parents
• Person-Centered Planning Meetings for me and my family
• Benefits Counseling for me and my parents
• Summer and After School Job opportunities
• Referrals to other programs and agencies that may help me
MPR will randomly select youth to see who gets to participate in the CUNY YTDP.
Selecting randomly is like a lottery or tossing a coin. It is a fair way to make sure that
everyone who wants to has a fair chance of participating.
(2) If I am selected and enroll in the CUNY YTDP, I will also be able to use special waiver
rules. These rules are listed at the end of this form.
(3) MPR will ask me to answer questionnaires two more times—one year from now, and
three years from now. Even if I agree to be in the study today, I do not have to answer
questions in the future.
(4) MPR will send me a $10 MetroCard to say “thank you” every time I answer their questions
in the future. This money will not change the benefits I receive from Social Security.
(5) If I am selected to participate in CUNY’s YTDP, from time to time staff will ask me or my
parents questions about my experience or observe me or my parents to evaluate the
program.
(6) The researchers will look at records they get from Social Security and other places such
as my school, Unemployment Insurance, Food Stamps, and TANF. They may look at
records through 2010.

•

I do not have to take part in this project and there is no penalty for dropping out whenever I
choose.

•

If I have any questions about this study, I can call Karen CyBulski at MPR. Her number is
609-936-2797 or 800-951-7357. If I am deaf or hard of hearing, I can call 877-542-6734 (TTY).

•

I can keep a blank copy of this form.

•

The person at Mathematica who explained the study to [NAME] and [NAME] is:

Name:
Signature:
(His/Her) signature means that (he/she) believes I understand the study.

Research and Treatment Consent Template – 6-28-06

Page 2

About the Privacy Act:
The Social Security Administration is allowed to collect the information asked for while you
participate in the Youth Transition Demonstration Project under section 1110 of the Social
Security Act. We use the information to decide what services would best help you. You do not
have to give us this information. However, if you do not, we will be unable to offer you services.
There are certain situations authorized by Federal law in which Social Security may release the
information you give us through this project. For example, we will release the information to a
congressional office in response to an inquiry that office may make at your request or to an
evaluation contractor hired by Social Security to evaluate the project.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this, contact
any Social Security Office.
•

•

YTDP Waivers from SSA:
If I receive benefits from Social Security and a continuing disability review or age-18
medical redetermination finds that I am no longer entitled to benefits, Social Security will
continue to pay benefits to me.
If I receive benefits from Social Security or become eligible for such benefits while
participating in the Youth Transition Demonstration Project, Social Security also will apply
the following special rules in determining my eligibility and benefit amount:
- In determining Supplemental Security Income (SSI) eligibility and payment amount,
Social Security will apply the student earned income exclusion to earnings
regardless of my age.
- In determining SSI eligibility and payment amount, Social Security will disregard the
first $65 plus three-fourths (instead of one-half) of any earnings over $65 if those
earnings are not covered by the student earned income exclusion.
- Social Security will apply the SSI rules for individual development accounts (IDAs)
that involve Federal funds to IDAs that do not involve Federal funds. That is, any
earnings I deposit to the account will not count as income, matching deposits will not
count as income, and the IDA will not count toward the SSI resources limit.
- Ordinarily, a plan for achieving self-support (PASS) must specify an
occupational goal at the outset. For participants in the Youth Transition
Demonstration Project. Social Security will approve an otherwise satisfactory
PASS that specifies either career exploration or post-secondary education as its
goal. If the goal is post-secondary education, an occupational goal must be
specified at least one year before completion of course requirements.

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.
We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating
to our time estimate to this address, not the completed form. The valid OMB control number for this information collection is
0960-0687.

Research and Treatment Consent Template – 6-28-06

Page 3

SIGNATURE PAGE
YOUTH
Please check (!) one of the following boxes and sign the form:
IF YOU WANT TO BE IN THE
STUDY, CHECK (!) THIS BOX

IF YOU DON’T WANT TO BE IN THE
STUDY, CHECK (!) THIS BOX

" YES, I agree to be in the Youth Transition

" NO, I do not want to be in the Youth

Demonstration Project study.

Transition Demonstration Project study.

Sign your name here:
Print your name here:
Write your Social Security Number in the boxes: |

|

|

|-|

|

|-|

|

|

|

|

PARENT OR GUARDIAN
Please check (!) one of the following boxes and sign the form:
IF YOU WANT YOUR YOUTH TO
BE IN THE STUDY, CHECK (!)
THIS BOX

" YES, I agree that [NAME] may be in the

IF YOU DO NOT WANT YOUR
YOUTH TO BE IN THE STUDY,
CHECK (!) THIS BOX

" NO, [NAME] may NOT be in the Youth

Youth Transition Demonstration Project
study.

Transition Demonstration Project study.

Sign your name here:
Print your name here:
By signing this consent, I authorize my child’s school to provide to the CUNY Youth Transition Demonstration Project
and MPR my child’s current Individualized Educational Program (IEP), student transcript, report card, and information
maintained in the NYC Department of Education's “Automate the Schools” and “Child Assistance Program” data base
systems when requested by the Project Director of the CUNY Youth Transition Demonstration Project.

Please place this form in the enclosed pre-paid envelope and mail it to:
Youth Transition Demonstration Project
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543

Research and Treatment Consent Template – 6-28-06

Page 4

Consent Form Approval
Date: July 26, 2006

Valid For Use Through: July 26, 2007
Colorado Multiple Institutional Review Board

CONSENT FORM
COMIRB Protocol: 05-0363
Colorado Youth WINS
Social Security Reference Award Number 12-Y-30003-8-01
Principal Investigators: Judith Emery and Thomas Fraker
Statement of Consent for the Study
I understand that:
•

I have been asked to be in a research study because I get benefits from Social Security. The
study is called Colorado Youth WINS.

•

The purpose of the study is to learn how youth with disabilities become as independent as they
can. The information may help others in the future. The study may or may not make it easier for
me to become independent. Up to 1,000 Colorado youth will be in the study.

•

Two groups are doing the study: Mathematica Policy Research, Inc. (MPR) and Colorado WIN
Partners. Colorado WIN Partners is part of the University of Colorado at Denver and Health
Sciences Center. The Social Security Administration (SSA) is paying for the study.

•

There is no cost to be in the study. Nothing harmful will happen to me because I am in the study.
There may be risks that the researchers have not thought of.

•

I answered questions on the telephone on [DATE]. If I agree to be in the study, the researchers
may use my answers. If I do not want to be in the study, the researchers will destroy my
answers. No one will be mad at me if I decide not to be in the study. If I decide not to be in the
study, nothing will happen to the benefits I get now.

•

All the answers that I gave on [DATE] or give in the future will:
(1) be kept confidential. Confidential means that the data will be kept as private as possible.
Information about me will be shared by MPR, Colorado Youth WINS, and SSA. If
information is shared with others, it will not be connected with my name.
(2) be protected by the Privacy Act. Information about the Privacy Act is at the end of the form.
(3) be used for research purposes. I still have to report my earnings directly to SSA just like I
would if I were not part of the study. This is so SSA can determine my benefits.

•

If I agree to be in the study, four things will happen:
(1) The researchers at MPR will give me a chance to get support from Colorado Youth WINS.
The support will be from a team of three people who will help me get services, understand
my benefits, explore career choices, and get a job. If I am selected and enroll in Colorado
Youth WINS, I will also be able to use special rules. These special rules will protect the
benefits I get from Social Security. MPR will select youth at random to see who gets the

Page 1

extra support. Selecting at random is like a lottery or tossing a coin. It is a fair way to make
sure that everyone who wants to get the extra support has a fair chance of getting it.
(2) MPR will ask me to answer questions two more times—one year from now, and three years
from now. I can answer those questions by telephone or in-person. Even if I agree to be in
the study today, I do not have to answer questions in the future.
(3) MPR will send me a $10.00 gift card to say “thank you” for answering questions. This money
will not affect the benefits I receive from Social Security.
(4) If I agree, the researchers will look at records from Social Security and other agencies such
as the Division of Vocational Rehabilitation (DVR), Unemployment Insurance Wage Records,
Colorado Temporary Assistance to Needy Families (TANF), Colorado Food Stamps,
Colorado Workforce Database (Job Link), Local Community Center Board (CCB), or
Colorado Department of Environment and Health. I will be asked to sign another form telling
the researchers which agency records they can look at. They may look at records until
September 30, 2009.
•

I do not have to take part in this project and there is no penalty for not volunteering or for
dropping out whenever I choose.

•

If I have any questions about this study, I can call Karen CyBulski at MPR. Her number is
609-936-2797 or 800-951-7357. If I am deaf or hard of hearing, I can call 877-542-6734 (TTY).

•

If I have questions about my rights as someone in this study, I can call the Colorado Multiple
Institutional Review Board (COMIRB). The number is 303-724-1055.

•

I can keep a blank copy of this form.
About the Privacy Act:
The Social Security Administration is allowed to collect the information asked for while you
participate in the Colorado Youth WINS under section 1110 of the Social Security Act. We use
the information to decide what services would best help you. You do not have to give us this
information. However, if you do not, we will be unable to offer you services.
There are certain situations authorized by Federal law in which Social Security may release the
information you give us through this project. For example, we will release the information to a
congressional office in response to an inquiry that office may make at your request or to an
evaluation contractor hired by Social Security to evaluate the project.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this, contact
any Social Security Office.

•

The person at Mathematica who explained this to [NAME] and [NAME] is:

Name:
Signature:
(His/Her) signature means that (he/she) believes I understand the study.
Page 2

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.
We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating
to our time estimate to this address, not the completed form. The valid OMB control number for this information collection is
0960-0687.

Page 3

SIGNATURE PAGE
YOUTH
Please check (!) one of the following boxes and sign the form:
IF YOU WANT TO BE IN THE
STUDY, CHECK (!) THIS BOX

IF YOU DON’T WANT TO BE IN
THE STUDY, CHECK (!) THIS BOX

" YES, I agree to be in the

" NO, I do not want to be in the

Colorado Youth WINS study.

Colorado Youth WINS study.

Sign your name here:
Print your name here:
Write your Social Security Number in the boxes: |

|

|

|-|

|

|-|

|

|

|

|

PARENT OR GUARDIAN
Please check one of the following boxes and sign the form:
IF YOU WANT YOUR YOUTH TO
BE IN THE STUDY, CHECK (!)
THIS BOX

IF YOU DO NOT WANT YOUR
YOUTH TO BE IN THE STUDY,
CHECK (!) THIS BOX

" YES, I agree that [NAME] may be in the

" NO, [NAME] may NOT be in the

Colorado Youth WINS study.

Colorado Youth WINS study.

Sign your name here:
Print your name here:

Please place this form in the enclosed pre-paid envelope and mail it to:

Colorado Youth WINS Study
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543

Page 4