Attachment F-Focus Group Informed Consent

ATTACHMENT F:

INFORMED CONSENT AND AGREEMENT TO PARTICIPATE

You are being asked to participate in this focus group to assist with evaluating the accessibility of American Job Centers (AJC) for people with disabilities. Please read this informed consent and agreement to participate form carefully and ask as many questions, as you like before you decide whether you want to participate in this focus group session. You are free to ask questions at any time before, during, or after your participation in this session. A person is not required to respond to a collection of information, unless it displays a currently valid OMB control number. The OMB number for this data collection is <insert OMB number>, which expires on <insert date>. If you have questions regarding this data collection request, please contact Stefanie Schmidt at the USDOL, Schmidt.Stefanie.R@dol.gov, 202-693-5901.

Project Title: Evaluating the Accessibility of American Job Centers for People with Disabilities

Facilitator: <insert name>

Note Taker: <insert name>

Purpose of the Focus Group: To capture, in your own words, your experiences, perceptions, challenges, source of satisfaction and dissatisfaction, and support received prior to, during, and after receiving services from the AJC.

Procedures: You will be asked to share your experiences and honest opinions about your experiences during a 90 minutes session.

Privacy and Anonymity: All of the information we collect in the survey will be kept private and will be used for research purposes only. Your name will never be used in any reports. Only members of the study team will have information about you. Your individual responses will not be shared with any state unemployment office or the U.S. Department of Labor. Your answers will be combined with the answers of other survey participants. Your responses are protected from disclosure by federal statute [P.L. 107-347, Title V Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA)].

Participant Consent and Agreement: I have read the information presented above about the focus group being facilitated by IMPAQ International/Burton Blatt Institute. I have had the opportunity to ask any questions related to this study, to receive satisfactory answers to my questions and any additional details I wanted.

I am aware that I have the option of allowing my interview to be tape recorded to ensure an accurate recording of my responses.

I am also aware that excerpts from the interview may be included in a report, with the understanding that the quotations will be anonymous.

With full knowledge of all foregoing, I agree, of my own free will, to participate in this focus group session and to keep in confidence information that could identify specific participants and/or the information they provided.

YES NO

I agree to have my interview tape recorded.
YES NO

I agree to the use of anonymous quotations in any reports that comes from this focus group session.
YES NO

Participant Name: ____________________________ (Please print)

Participant Signature: ________________________ Date: ____________

Witness Name: ________________________________ (Please print)

Witness Signature: __________________________ Date: ____________

IMPAQ International, LLC Attachment F-1 Informed Consent and

Agreement to Participate