Attachment B_Informed Consent Form_revised 10-2-12

Attachment B: Consent Form

OMB Control No. 0970-0394 OMB approval expires xx/xx/xxxx Abt Associates IRB Approval No. 0572 Urban Institute IRB Approval No. 08592-100/110-00

AGREEMENT TO TAKE PART IN THE
HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM (HPOG)

RESEARCH STUDIES

The Health Profession Opportunity Grant (HPOG) program is a new job training program being funded by the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) in Washington, DC. The HPOG program is intended to help people improve their skills, find jobs, and advance in healthcare careers. HHS has funded Abt Associates and The Urban Institute to conduct two related research studies of HPOG to learn how well the program works. This form (1) describes these two studies being conducted about HPOG and (2) requests your participation in these studies. We need to tell you about these two studies and what it means to be part of them, because only individuals who agree to participate in the studies will be able to enroll in the HPOG program.

Research Overview

The two studies of HPOG being funded by HHS are described below:

1. The HPOG National Implementation Study. This evaluation will describe and evaluate how HPOG operates. As part of this evaluation, the study team will collect data about all HPOG grantees and all individuals who enroll in HPOG.

2. The Impact Study of the Health Professions Opportunity Grant (HPOG-Impact). Over the next 12 – 16 months, the [name of HPOG program] will also be in the HPOG-Impact study. The study will assess if and how HPOG makes a difference in people’s lives, especially in helping them complete training and getting healthcare jobs

The studies also will help the government learn how to improve the HPOG program, and other similar programs, in the future. As part of the impact study, the study team will collect data from individuals enrolled in the regular HPOG program, from individuals enrolled in the “enhanced” HPOG program (slightly different from the regular HPOG program), and from a control group comprised of individuals who are not enrolled in HPOG. We expect a total of 10,250 individuals at up to 20 HPOG grantees to participate in HPOG-Impact.

Following paragraph applicable to participants at grantees NOT implementing systematic variation

During the period of the impact study, entry into the HPOG program will be by lottery.

If you are an eligible applicant for [name of HPOG program], you will take part in a lottery to see if you will be invited to participate in [name of HPOG program], or you will not be invited to participate in [name of HPOG program]. If you are not invited to participate, you will not be able to enroll in [name of HPOG program], but can enroll in any other service or program you are eligible for. Participation in this study is voluntary. If you choose not to be a part of this study, you will not be able to participate in the lottery for the HPOG program. However, you will be able to enroll in any other service or program you are eligible for.

Following paragraph applicable to participants at grantees implementing systematic variation

During the period of the impact study, entry into the HPOG program will be by lottery.

If you are an eligible applicant for [name of HPOG program], you will take part in a lottery to see if you will be invited to participate in one of two programs operated by [name of HPOG program], or you will be assigned to the non-HPOG group. If you are assigned to the non-HPOG group, you will not be able to enroll in [name of HPOG program], but can enroll in any other service or program you are eligible for. Participation in this study is voluntary. If you choose not to be a part of this study, you will not be able to participate in the lottery for the HPOG program. However, you will be able to enroll in any other service or program you are eligible for.

The researchers need your permission to get information about you so they can understand the types of people in the program and how well the program is working. For the research studies, researchers want: 1) information about the training and services you get in the program or outside the program if you are not in the HPOG program; (2) information about you and your family, your education, and work history; (3) personal data such as your Social Security number so they can get information from government sources about your future employment, earnings, education, and public benefits like welfare; and (4) if you have children, we would like to request information about their birthdates and names, so that in the future, we may follow up with age-appropriate questions about their experiences. You may refuse to answer any specific question at any time.

By participating in these studies, you will help the federal government and programs around the country learn about the best way to provide training and help participants get a health care job. You will be asked for information at certain times during your participation in the program and after you leave the program. You may be contacted by a researcher after you leave the program to answer some questions about your experiences. If so, you will be compensated for your time in answering questions. While we encourage you to answer their questions, you may refuse to answer them.

Abt Associates, The Urban Institute and future researchers will use data security procedures to keep all of the study data private and to protect your personal information. All of the information used in research will be kept private to the extent allowed by law. Your name will never appear in any report or with any research findings. The researchers will combine the information about everyone in the program to analyze how the program helps people find and keep a job in healthcare. Any forms or other papers that include your name will be kept in a locked storage area, and any computer files with your name will be locked and protected. Any researchers using information to study the program must follow all data security procedures and sign a privacy agreement.

This agreement is effective from the date you sign it (shown below) until the end of the research studies, or when you choose to withdraw permission. You may choose to withdraw your participation at any time. If you do withdraw, researchers will continue to use information collected during the time you consented.

For questions or concerns about your rights as a research participant, call Teresa Doksum at the Abt Associates Institutional Review Board at toll-free 877-520-6835. For questions or concerns about the research, call Alan Werner (Abt Associates) at toll-free 855-551-0919.

Statement

“I have read this form and agree/do not agree to allow information about me to be used in the national Health Profession Opportunity Grant Program research studies. I know that if I do not consent to be in the research I will not be able to enroll in the [name of HPOG program] program. Abt Associates, The Urban Institute and any future researchers will use data security procedures to keep all of the study information private as described above, and my name will never appear in any public report. I know that I can refuse to answer any questions researchers might ask me. I understand that Abt Associates, The Urban Institute and other researchers may contact me in the future and will use my personal information to get information about me from other sources, as described above.”

PRINT YOUR NAME ABOVE

IF YOU AGREE TO LET RESEARCHERS USE YOUR INFORMATION, SIGN ABOVE

IF YOU DO NOT AGREE TO LET RESEARCHERS USE YOUR INFORMATION, SIGN ABOVE

DATE

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0394. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This information collection is voluntary. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Attachment B: Consent Form  ▌pg. 2