Appendix B_Consent Forms

OMB # 0970-0356

Expiration Date: 01/31/2015

Appendix B: Consent Forms

Adult Consent form for Staff and Administrators¹

Behavioral Interventions to Increase Self-Sufficiency Project Information Collection

You have been invited to participate in a <focus group or interview> that will help gather information for the Behavioral Interventions to Increase Self-Sufficiency (BIAS) Project. Your participation will help us better understand the experience you have had with the service or program. A nonprofit research organization called MDRC and another called ideas42, both located in New York, NY are conducting this study for the Administration for Children and Families at the U.S. Department of Health and Human Services. We are talking to many individuals like you who are employed by, or who receive services from ACF programs.

The purpose of the study is to learn more about the delivery of services from the perspective of administrators, employees and clients in programs funded in part or in full by the Administration for Children and Families (ACF). We will ask you things like your role or experience in the program or description of each of the steps that clients go through to receive services. If you agree to participate, you may be asked to join a group with other individuals who also have experience with the program or services. The discussion will last about one hour and will be audio-recorded.

Your privacy is important. Audiotapes, transcripts and notes will be taken during the discussion. Your answers and discussion will only be shared with the research team and not with ACF. We may select some comments because they help make a point but none of these will be personally identified. If you have any comments you do not want us to use word-for-word, please let us know before or after you say them, or after we are done. If the discussion takes place with a group, we will ask everyone in the focus group to respect the privacy of others, and try not to talk about sensitive issues. MDRC and ideas42 cannot promise that everyone in the group will keep anything you say private. Feel free to share your questions or concerns with the moderator before, during, or after the discussion.

Your participation is voluntary and you may leave at any time.

Your participation or non-participation will not affect the services you receive or your employment.

There are no known risks associated with participating in this study.

If you have questions about the study, you may write or call Lashawn Richburg-Hayes, project director, MDRC at 16 East 34^th Street, New York, New York, or 212-532-3200. If you have questions about your rights as a research subject, you may write to the MDRC Institutional Review Board at 16 E. 34^th Street, NY, NY 10016 or call 212-532-3200.

If you decide to participate after reading this form, sign and date the form.

_______________________ __________ Participant’s Name Date _______________________ Participant’s Signature

_______________________ __________ Investigator’s Name Date _______________________ Investigator’s Signature

Adult Consent form for Clients²

The Behavioral Interventions to Increase Self-Sufficiency Project Information Collection

You have been invited to participate in a <focus group or interview> that will help gather information for the Behavioral Interventions to Increase Self-Sufficiency (BIAS) Project. Your participation will help us better understand the program services you offer, the type of data collected to track services, and the experience clients have had with the service or program. A nonprofit research organization called MDRC and another called ideas42, both located in New York, NY are conducting this study for the Administration for Children and Families (ACF), U.S. Department of Health and Human Services. We are talking to many individuals like you who are employed by, or who receive services from, ACF programs.

The purpose of the study is to learn more about the delivery of services from the perspective of administrators and employees as well as clients, in programs funded in part or in full by ACF. We will ask you things like your role or experience in the program, a description of the steps that clients go through to receive services, and aspects of service delivery that are easy or hard. If you agree to participate, you may be asked to join a group with others who also have experience with the program or services. The discussion will last approximately one hour and will be audio-recorded.

Your privacy is important. Audiotapes, transcripts and notes will be taken of the discussion. Your answers and discussion will only be shared with the research team and not with ACF. We may select some comments because they help make a point but none of these will be personally identified. If you have any comments you do not want us to use word-for-word, please let us know before or after you say them, or after we are done. If the discussion takes place with a group, we will ask everyone in the focus group to respect the privacy of others, and try not to talk about sensitive issues. MDRC and ideas42 cannot promise that everyone in the group will keep anything you say private. Feel free to share your questions or concerns with the moderator before, during, or after the discussion.

Your participation is voluntary and you may leave at any time.

Your participation or non-participation will not affect the services you receive.

There are no known risks associated with participating in this study.

If you have questions about the study, you may write or call Lashawn Richburg-Hayes, project director, MDRC at 16 East 34^th Street, New York, New York, or 212-532-3200. If you have questions about your rights as a research subject, you may write to the MDRC Institutional Review Board at 16 E. 34^th Street, NY, NY 10016 or call 212-532-3200.

If you decide to participate after reading this form, sign and date the form.

_______________________ __________ Participant’s Name Date _______________________ Participant’s Signature

_______________________ __________ Investigator’s Name Date _______________________ Investigator’s Signature

1 THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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.

2 THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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.