OMB Control Number: 2528-0296
Expiring: XX-XX-XXXX
AGREEMENT TO PARTICIPATE IN THE
NATIONAL FAMILY SELF-SUFFICIENCY (FSS) STUDY
You are invited to take part in the National Family Self-Sufficiency (FSS) Study, which tests an employment and self-sufficiency program for households receiving Section 8 housing vouchers.
By signing this form, you are agreeing to be in the FSS Study and to make available to the research team different types of data, described below, that are needed to conduct the study.
This form describes the National FSS study and explains what it means for you.
What is the National Family Self-Sufficiency (FSS) Study?
The FSS program offered by [PHA] connects participants to employment and support services and offers a special five-year savings account called an “Escrow Account.” Under the Housing Choice Voucher program (also called Section 8), households often pay higher rent when their earnings increase. Voucher households enrolled in the program under study also pay higher rent when their earnings increase, but [PHA] will deposit the increased rent amount in the household’s escrow account. Savings in the escrow account will be available to households with an escrow account upon graduation from the program, or sooner, if the PHA allows. The attached flyer provides additional information on the program and the National FSS Study.
The National FSS Study will test whether the program is effective in improving the economic well-being of households receiving Section 8 vouchers. Individuals who agree to be in the National FSS Study will be placed at random into one of two groups, along with all other members of their household who enroll in the program:
The FSS Group: This group will have access to the program’s employment and support services as well as the escrow account.
The Control Group: This group will continue to receive their housing voucher but will not be eligible for an escrow account or receive the program’s additional employment and support services from [xx PHA] for 5 years or until the research team stops collecting information for the study, whichever comes sooner.
A procedure called “random assignment” is used to place individuals into the two groups. Random assignment is like picking names out of a hat. Half the households that sign up for the National FSS Study will be placed in each group. The decision is made by a computer program and is not based on your personal characteristics or background. Assignment to one of the two groups occurs purely by chance.
Who is running the National FSS Study?
The research team includes the U.S. Department of Housing and Urban Development, Office of Policy Development and Research, who is funding the National FSS Study; MDRC and Branch Associates, two social policy research organizations that will perform most of the research; and M. Davis and Company, Inc., a survey firm.
In 2013, HUD-PDR will select additional researchers from universities or research organizations. These researchers will undergo strict review by HUD-PDR and by a separate group called an Institutional Review Board at their university or organization. They will be required to conduct additional research related to FSS in an ethical way and protect the confidentiality of the data that they collect.
HUD-PDR will approve the topics of their research and the data sources that they will use.
What does it mean to take part in the National FSS Study?
If you take part in the National FSS Study and sign this form, the research team will collect some information about you and hold on to the information for up to 10 years.
Here is the type of information the research team will definitely collect:
Identifying information about you: Such as your name, address, phone number, date of birth, Social Security Number, Public Housing Authority Household ID Number, date of birth, and other information that could be used to contact you or to collect information about you for this study.
Background information: This includes your gender, race or ethnicity, education, education, and other topics. You will receive a $25 gift card for completing a short interview at the time of study enrollment.
Employment-related services and supports: Information on the services you receive from records created by program staff.
Housing Authority data: The research team will collect information about your household, such as the number of people who live with you, and about your household income, assets, rent, and the balance in your escrow account, as well as participation in any other programs run by the [PHA].
Employment and Earnings: The research team will collect information about your employment and earnings from [name state agency] Unemployment Insurance Wage records or from Unemployment Insurance Wage records kept by a federal agency, the U.S. Department of Health and Human Services.
Follow-Up interviews: In the future, you may be contacted to complete one or more additional interviews about your experiences with the program, your employment, household income, housing, financial circumstances, and your general well-being. You will get a gift card for each interview you complete, but you do not have to participate in any survey nor answer any questions that make you uncomfortable.
The research team may collect additional information on you for the National FSS Study:
Public Benefits: The research team may collect information from [name state agency]or records kept by the U.S. Department of Health and Human Services about your receipt of one or more of the following public benefits: Unemployment Insurance Benefits; Food stamps/SNAP; TANF/welfare; and Medicaid or other types of publicly financed health coverage.
Information about you collected from other public agencies, such as public health agencies or agencies that keep vital statistics.
In addition, the research team may conduct additional research on the health and school performance of children who live in households in the National FSS study. If the research team decides to study these topics, members of the team may collect one or more of the following types of information on your children under the age of 18 years who live with you:
Identifying information from housing authority records: Such as each child’s name, Social Security Number, Housing Authority Household ID Number, date of birth, and other information that could be used to collect information about them for this study.
Information about your children collected from schools or other public agencies. The research team may collect information from schools, local education agencies, child welfare agencies, health departments, or other agencies.
Who is eligible for the National FSS Study?
You can take part in the National FSS Study if you are at least 18 years old and are listed on the Section 8 voucher lease.
Our promise about your privacy
The research team will follow strict rules to keep all data collected about you private. Your data will only be used for conducting research on the program. Your name will never appear in any public document. Data that could be used to identify you, such as your name or Social Security Number, or Housing Authority ID Number will be kept locked up or stored in password protected computer files and will not be publicly distributed. Members of the research team may tell someone if harm to you, harm to others, or child abuse becomes a concern. Members of the research team will follow strict rules to protect all of the data and no data will be disclosed to outside parties – including administrators or employees of the U.S. Department of Housing and Urban Development who do not work for HUD-PDR.
All personally identifiable data about you or children under the age of 18 who live with you will be destroyed or returned to their respective agency upon the conclusion of the study. Further, the research team will stop collecting any personally identifiable data about the children once they turn 18 years.
There is very little risk in taking part in the National FSS Study. The rules concerning your rent payments and housing established by the PHA will not change. In addition, the information collected for the National FSS Study will be kept confidential and will only be used for research purposes. Furthermore, you do not have to answer any questions that make you uncomfortable.
In some situations, the amount of money that you receive from your escrow account may affect your future eligibility to receive cash or other government benefits or health coverage from government agencies. Talk with a counselor at [PHA] or the agency that provides the benefit for more information about the income and asset eligibility limits for these benefits.
Participation in the National FSS Study is voluntary
You do not have to sign up for this study. However, [until date, if known, else] for about one year, only people who sign up for the study will have a chance to be selected to receive services from the program or have an escrow account. After that date, households not in the National FSS study should contact [PHA] about whether services or escrow accounts are available.
If you want to leave the study later, you may do so by contacting James Riccio, Project Director, by mail at MDRC, 16 E. 34th Street, New York, NY 10016, by phone at 212-532-3200, or by email at james.riccio@mdrc.org. MDRC will contact you to confirm your withdrawal from the study. If you withdraw from the National FSS Study, any information collected by the researchers before that time may still be used for this study. In other words, any data that are collected before you withdraw can still be included in the research, but no additional data will be collected.
Your decision to leave the National FSS Study will not affect your eligibility for services from [PHA]. If you are assigned to the FSS Group and leave the National FSS Study, you may continue to receive services from the program and may continue to have an escrow account.
Effective dates
This agreement is effective from the date you sign it until the end of the study. While the program lasts 5 years, the study will last for at least 10 years. Data collected will include information from 2011 through the end of the study.
Statement of Agreement for the National Family Self-Sufficiency (FSS) Study
I have read this form and know that my participation is voluntary and that the members of the research team for the National FSS Study — U.S. Department of Housing and Urban Development, Office of Policy Development and Research (HUD-PDR), MDRC, Branch Associates, M. Davis and Company, and additional researchers chosen by HUD-PDR in 2013 — will follow strict rules to protect my privacy.
I understand that members of the research team will use the data only for the purposes of conducting research on the program under study and not for any other purposes without my prior written consent.
I know that I can refuse to answer any questions or stop being in the study at any time.
I consent to the release of information about me and about my children under the age of 18 years who live with me by [PHA] and other listed agencies to conduct the National FSS Study. I understand that the research team will collect information about us from [PHA] and other agencies, as described above, and that they will use our Social Security Numbers, Public Housing Authority Household ID Number, names, and date of birth to get this information.
________________________________ ____________________________ Name of Study Participant (Print) Signature of Study Participant
________________________________ Household Identification Number
_______________________________ _____________ Signature of Staff Member Date |
If you have questions about the study, contact MDRC at 212-340-7587. Or write to: James Riccio, MDRC, 16 E. 34th Street, New York, NY 10016. If you have questions about the FSS program, please call xxx-xxx-xxxx (local contact) or visit the website at xxxx.
Privacy Act Notice
This research is conducted under the authority of the Secretary of the U.S. Department of Housing and Urban Development to undertake programs of research, studies, testing and demonstration related to the mission and programs of HUD (12 USC 1701z-1 et seq.). The information collected for this study will be used only for research. It is protected by a Federal law called the Privacy Act of 1974.
| File Type | application/msword |
| File Modified | 2016-07-29 |
| File Created | 2016-07-29 |