AFI OMB Package - Attachments - Revised Consent - 5

SUPPORTING STATEMENT FOR THE

ASSETS FOR INDEPENDENCE (AFI)

PROGRAM EVALUATION

ATTACHMENTS

Office of Planning, Research, and Evaluation

Administration for Children and Families

U.S. Department of Health and Human Services

370 L'Enfant Promenade, SW

Washington, DC 20447

Contract Number HHSP23320095654WC

Order Number HHSP23337032T

Updated May 2013

Table of Contents

ATTACHMENT E Informed Consent

Attachment E

Informed Consent

OMB #: 0970-XXXX

Expiration Date: XX/XX/2015

ASSETS FOR INDEPENDENCE (AFI)

PROGRAM EVALUATION

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 30 minutes for the baseline and follow-up questionnaires, for a total of 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.

Consent form to participate

PURPOSE OF THE EVALUATION

An evaluation study of the Individual Development Account (IDA) program operated by the {FILL SITE NAME} is being conducted by the Urban Institute and RTI International on behalf of the U.S. Department of Health and Human Services. The purpose of this study is to assess the impact of IDAs on the economic well-being of households such as yours. You are one of approximately 1,100 individuals being asked to participate.

STUDY PROCEDURES

If you agree to participate in the study, you will be asked to complete a 30 minute self-administered survey via computer today and then to complete annual follow-up surveys via telephone for the next three years. The question topics include your employment and financial experiences, housing status and satisfaction, lifestyle and health issues. For each survey that you complete, which will take approximately 30 minutes, you will receive $20 as a token of appreciation.

Additionally, if you agree to participate in the study, [organization] will obtain your credit score and credit report on a soft-inquiry basis that will not affect your credit score. This will be done once you enter the study and then annually for the next three years, whether you are assigned to the program group or the comparison group. To enable [organization] to do this, you will need to sign a separate authorization form.  Each time [organization] obtains your credit score and credit report, they will review it with you.

The Urban Institute researchers will use the credit score for statistical purposes only, to better understand the IDA program. Your credit score is not a factor in determining your IDA program eligibility. They will keep your credit score private; it will be stored separately from your name and address.

RANDOM ASSIGNMENT AND IDA BENEFITS

If you decide not to participate in the study, you will need to wait for up to eighteen months before being allowed to apply again for the IDA program at [FILL SITE NAME].

For those who agree to participate in the study, we will use a random assignment procedure (like a lottery) to determine whether or not you are allowed to enter the IDA Program. Each study participant has a 50-50 chance of being allowed to enter the IDA Program, as a member of the study’s “treatment group.” Those not selected to enter the program can still receive any other benefits and services offered by [FILL SITE NAME], as a member of the study’s “control group.” You will be notified of your group assignment at the end of the computer interview today.

If you are selected for the [FILL SITE NAME] IDA Program, you will need to submit financial information, including information from your IDA account at the Bank of [FILL NAME] to the Urban Institute and RTI International for the purpose of this evaluation.

POTENTIAL RISKS AND DISCOMFORTS

In today’s computer questionnaire or in the annual follow-up surveys, you may find some of the questions to be personal. You may refuse to answer any question and you may take a break at any time during an interview.

POTENTIAL BENEFITS

There are no immediate program benefits or services provided to those completing today’s computer survey. For each survey that you complete, you will receive $20 as a token of appreciation. This evaluation may also generate support for government policies that offer resources to households such as yours for investment in long-term economic growth.

PRIVACY

All of the information you provide will be kept private to the extent permitted by law, and we will never publish, release, or share your personal information. Many precautions have been taken to protect your information. Information such as your name and address will be stored separately from the answers you provide on the online survey.

PARTICIPATION AND WITHDRAWAL

Your decision to take part in this study is completely voluntary. You can refuse any part of the program and you can stop participating at any time. You can refuse to answer any question in the computer survey or any follow-up survey. You will not be penalized in any way should you choose not to participate or withdraw. If you have any questions about the project, you may call Melissa Hobbs, the Data Collection Task Leader, at 1-800-334-8571, 25744. If you have any questions about your rights as a study participant, you may call the Administrator of the Institutional Review Board at the Urban Institute, at X (a toll-free number).

By agreeing to participate in this research, you are not giving up any of your legal rights.

The site administrator will record in the computer your decision about participation. We will also provide a copy of this consent form to you for your records.

__________________________________________ _____/____/____

Participant’s Signature Date (mo/day/yr)

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Participant’s Name (first and last name): Please Print