Marginal Tax Rates and Work Disincentives: Family Perceptions and Labor Force Decisions

OMB Control Number: 0990-0421

Expiration Date: October 12, 2020

Attachment D: Consent Form

PURPOSE: This will be used to document each participant’s consent to participate in the focus group and be recorded. Insight will retain one copy of the consent form and provide a copy to each participant.

You have been selected to participate in a research study being conducted by the U.S. Department of Health and Human Services (HHS). The purpose of this study is to understand how families make decisions about work and their government benefits, including their [PROGRAM NAME] benefits.

If you agree to participate, here are some things you should know:

• Your participation is completely voluntary (not required) and will not affect your benefits in any way.

• Your actual name will never be used in any reports about this discussion. We will ask focus group participants to choose a pseudonym, or “fake name,” for use during the discussion instead.

• All information collected during this study will be kept private; this means nobody outside of the research team will see your responses attributed to you by name, and your responses will not be identified individually by your actual name.

• With your permission, the discussion will be recorded and transcribed. We will talk with many people across the country, so this step will help us keep track of and accurately report the things we learn. We will not share any information that might identify you with anyone from the government or benefits office, and we will destroy the recording when the study is over.

• Your input will help HHS understand families’ experiences, circumstances, and needs regarding benefits and work.

• You may choose to not answer any questions. You may also leave the discussion at any time.

• Your benefits (for example, [LOCAL PROGRAM NAMES: TANF, CCDF, Rental Assistance]) will not be affected in any way if you stop participating in the discussion or decide not to answer a question.

• The discussion leader will answer any questions you have about the discussion or the forms.

• The discussion will last about 90 minutes.

• At the end of the focus group, you will receive a $50 gift card to help compensate you for the time you are taking to participate in the focus group today.

Contact Information: HHS has authorized Insight Policy Research to conduct this study. If you have any concerns about your participation in this discussion or have any questions about the study, please contact the study director, Rachel Gaddes, at Insight Policy Research at 703-504-9489.

Certification: By signing this document, you are certifying that you have read this agreement. Please check the relevant box below to indicate whether you agree to participate and to have the discussion recorded.

I agree to participate in this study and have the discussion recorded.

I do not wish to participate in this study or have the discussion recorded.

Name [PRINT]:_________________________ Signature: _________________________ Date: ________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXX. The time required to complete this information collection is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.