Participant Informed Consent Form

OMB Control Number: 0938-NEW
Expiration Date: TBD

Focus Group Participant Informed Consent:
Montana HELP Evaluation

ALL PARTICIPANTS WILL SIGN ONE COPY OF THIS FORM AND PROVIDE IT TO THE RESEARCH TEAM. THEY WILL ALSO RECEIVE A COPY OF THIS CONSENT FORM FOR THEIR RECORDS.

Study Title: Montana HELP Evaluation

Principal Investigator: _[name and contact information]___________________________

Sponsor’s Name: Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services

Introduction/Purpose

You have been invited to participate in this study of the Montana Health and Economic Livelihood Partnership (HELP) program. The study is being funded by the Centers for Medicare and Medicaid Services, which is part of the U.S. Department of Health and Human Services. The Department of Health and Human Services hired the Urban Institute, the place where I work, to do the study for them. As part of our study, we are conducting focus groups with current enrollees in the HELP program. Results from our study will help state and federal officials better understand how well the HELP program is working. You were picked to participate in this study because you are currently enrolled in HELP and have been for at least 4 months. Before you agree to be a part of this study, you need to understand the risks and benefits of participating.

Procedure

If you agree, you will be participating in a focus group. A focus group is an informal small group discussion, with a discussion leader (that is me), who will guide the group through a series of questions focused on a certain issue. In our focus group, I will ask questions about your experiences being enrolled in the HELP program. My colleague, (name), will be taking written notes of your answers to my questions. The focus group will also be audio recorded, with your permission. Audio recording will only begin once focus group participants have all agreed that it is okay for us to record. If you do not agree to have the focus group recorded, please let me know. No one from the state or federal government will be at the focus group.

There are no “right” or “wrong” answers to the questions I’ll be asking during the focus group. We are interested in learning about your experiences and opinions being enrolled in HELP. You may choose to not answer any and all questions that are asked. You also may leave the focus group discussion at any time. The focus group discussion will last approximately 90 minutes.

Benefits

Participating in this focus group discussion may not benefit you, directly. However, while you may not benefit directly, your comments will help the government better understand how the HELP program is working for people like yourself who are enrolled in the program.

Risks

There is a small amount of risk to you by participating in this focus group. We have made every effort to reduce any risk to you and to make sure everything said in this group is kept private to the extent permitted by law, but we cannot control how other focus group participants act outside of this focus group. Therefore, you may decide not to answer any questions that make you feel uncomfortable in any way. There may be questions that you think are sensitive, such as whether you are unsatisfied with your current health coverage under HELP. You are not required to answer any questions if you do not wish to answer them. If there is something really important that you’d like to tell us, but don’t feel comfortable doing so in the group setting, here is a phone number and email address that you can use to reach us at any point after the conclusion of today’s focus group: (XXX) XXX-XXXX; XXX@Urban.org.

Participation Thank You Gift

To thank you for your participation, you will receive a gift card worth $60.00 at the end of the session. This gift card for participating will not count against your income or eligibility for public assistance. You will be asked to initial a form, indicating your receipt of this gift card.

We will also serve light refreshments during our discussion.

Privacy

All of the information that you provide us is guaranteed to be kept private (to the extent permitted by law) as we develop our notes and study reports. Information from the study will be reported in total, meaning you will not be personally identified in any report or publication of this study or its results. Recordings from each focus group will be stored in a protected folder on a computer that needs a password to unlock and that can only be accessed by the study's research team. The computer folder with the recordings will be deleted after the project is over. We will keep any records that we produce private to the extent permitted by law. The Urban Institute can guarantee only the privacy of the notes and recorded information from the focus group. If you agree to participate in this study, you must also agree to not share other focus group participants’ names or remarks with others outside of this group.

Participation is Voluntary

Your participation in this group, if you agree to take part, is voluntary. You have the right to change your mind or stop participating at any time without penalty. You also have the right to refuse to answer any questions during the focus group.

Questions

If you have any questions about this focus group, including any questions that concern your rights as a participant on the project, you can contact ________________ at (___) ___-____. If you have any questions about your rights as a participant in this study, you may also contact the Urban Institute Institutional Review Board at (___) ___-____. This Review Board oversees the protection of people that participate in research studies that Urban Institute employees like me conduct.

Agreement Statement:

Do you agree to participate in the focus group for the study of the HELP program?

Yes ______ No ______

Do you agree to have this focus group recorded?

Yes ______ No ______

Date of consent: ____________________________________

Name of focus group moderator (print): ____________________________________

Signature of focus group participant: ____________________________________

Participant name (print): ____________________________________