Appendix C Consent Form YEARS Web-based Staff Survey

OMB Control No.:xxxx-xxxx

Expiration Date: xx/xx/xxxx

Participant ID: ________

Interviewer Initials: _____

IRB # xxxx.xx.xxx

Approved on: xx/xx/xxxx

Valid until: xx/xx/xxxx

Consent Form—Youth Education and Relationship Services Web-based Staff Survey

Child Trends, an independent research organization, is contracting with the Administration for Children and Families in the U.S. Department of Health and Human Services to conduct a research study to describe Office of Family Assistance (OFA)-funded youth-serving Healthy Marriage and Relationship Education (HMRE) programs, including participant and partner characteristics, and program implementation characteristics. We are surveying program directors/administrators and facilitators. This form has information to help you decide if you want to respond to the survey.

1. PURPOSE:

We would like to ask you about your experiences providing HMRE services to youth aged 14-24. Our goal is to better understand the OFA-funded HMRE services being provided to youth aged 14-24.

2. PROCEDURES:

If you agree, you will participate in a 20 minute, web-based survey. During the survey, you will answer questions about how your organization provides HMRE services to youth aged 14-24. The survey will ask questions about the youth served, the program staff, implementation practices, and program and organizational characteristics.

3. RISKS AND/OR DISCOMFORTS:

Risks associated with participation include potential loss of privacy. To protect your or your organization’s privacy, your name or your organization’s name will not be used in reports and your individual responses will not be shown to anyone outside of the study team. To help ensure respondents’ privacy, participants will be provided a separate link to give their contact information at the end of the survey so that they can receive their gift card.

4. VOLUNTARY PARTICIPATION:

This collection of information is voluntary and will be used to better understand and improve HMRE programs. You can choose to stop the survey at any point. If after completing the survey you no longer wish to participate, you may contact Shelby Hickman at 240-223-9341 to have your organization’s responses removed from the study.

5. PRIVACY:

All information will be kept private to the extent permitted by law. Study reports will describe findings in general terms and will not include any names or any other identifiable information. OFA will not know which organizations participated in the survey, and your organization’s participation will not affect current or future funding from OFA.

6. COSTS AND BENEFITS:

There are no costs associated with the survey other than the time you spend completing the survey. You will not benefit personally from being involved in the study.

7. INCENTIVE:

To thank you for your participation, you will receive a $10 Visa gift card.

8. QUESTIONS:

If you have any comments or concerns about participating in this study, you can contact Mindy Scott, Study Director, at 240-223-9324. If you wish, you may also contact the Child Trends Institutional Review Board by calling 1-855-288-3506, by emailing irbparticipant@childtrends.org or by writing to 7315 Wisconsin Avenue, Suite 1200W, Bethesda, MD 20814.

9. CONSENT:

Do you agree to participate?

• I AGREE TO PARTICIPATE

• I DO NOT AGREE TO PARTICIPATE

NOTE: The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to better understand the Healthy Marriage and Relationship Education (HMRE) services provided for youth aged 14-24. Public reporting burden for this collection is estimated to average 30 minutes, 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. The OMB control number for this collection is XXXX-XXXX and it expires on XX/XX/XXXX.

Appendix C: Consent Form—YEARS Web-based Staff Survey
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