Consent Form for Linking Data - Los Angeles Site

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix A-6: Consent Form for Linking Data—Los Angeles site

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information collection is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer (Attn: OMB/PRA 0970-XXXX), Administration for Children and Families, Department of Health and Human Services, 370 L'Enfant Promenade, S.W., Washington, D.C. 20447.

In efforts to better understand your families’ experiences, health, and well-being during the past few years, we are interested in analyzing the information you provided for the Best Start LA surveys that you completed. If you recall, the survey data you provided to the research team from UCLA is being kept private, meaning no one but the research team at UCLA knows the data is yours. The Urban Institute would like to request your permission to obtain your survey data from UCLA for the purpose of analyzing that data with the interview data you shared with me today. Having access to both sets of data will improve the results of our study since we will know more about your experiences over time.

Do we have your consent to obtain your Best Start LA survey data?

Signing this consent form indicates that you give the University of California, Los Angeles permission to release your Best Start LA survey data to the Urban Institute.

_________________________________________

Respondent’s Name (PLEASE PRINT)

_________________________________________

Respondent’s Signature

_________________________________________

Date

1