Attachment 1-Informed Consent Form

INFORMED CONSENT FORM

Evaluation of the Family Unification Program

Family Unification Program Evaluation

A team of researchers from the Urban Institute, Child Trends, and Chapin Hall at the University of Chicago is working with the U.S. Department of Health and Human Services, Administration for Children and Families (ACF) to see if the Family Unification Program [known as [SITE NAME FOR PROGRAM] in [SITE]] is working. We would like to talk to you because you received a housing voucher through this program.

PURPOSE OF THIS INTERVIEW

This interview is part of our evaluation of the Family Unification Program. The goal of this study is to see if the program is working and to improve how the program works. We want to hear about your experiences applying for and searching for housing; and how it was to work with the child welfare agency, the public housing authority, and anyone else who has helped you as part of this program.

TYPES OF QUESTIONS

The interview will take about one and a half hours at your home or at a location of your choosing. The interviewer will ask questions about your housing history and your current housing and neighborhood. You will also be asked about services you or your children have received through the program and your experiences in the program.

VOLUNTARY PARTICIPATION

If you sign the attached release form, the Urban Institute will contact you to give you more information about the study and schedule an interview. By signing this form, you also give consent for your name and contact information to be taken from [PUBLIC HOUSING AUTHORITY] administrative records and shared with the Urban Institute. We need to collect this information so that the Urban Institute can get in touch with you about participating in the interview. When the Urban Institute contacts you, they will ask if you would like to participate in the interview. You can say no at that point, even if you signed this form. Even if you agree to the interview, during the interview you can refuse to answer any or all questions. Your refusal would not affect any benefits that you or your children may be receiving. You have the right to stop the interview at any time.

BENEFITS

There are no direct benefits to you from answering our questions. However, you will help us learn more about how the Family Unification Program works and how it can be improved to help families like yours. You will receive a $35 gift card to thank you.

RISKS

There are no physical risks to you from participating in this interview. It is possible that some questions might make you uncomfortable or feel various emotions, such as sadness. If you want to talk to someone about some of the things that may have happened to you or your children, the interviewer can provide you with a list of resources. If we learn during the course of these interviews that your life or health or the life or health of your child is in danger, we will share that information with the appropriate county or state agency. More information is provided in the Privacy section below.

PRIVACY

With your permission, the interview will be recorded to help us check our notes. The recording will be saved on a secured server and will not include your name or any other identifying information. Instead, it will be labeled with an identification number. Any information collected about you will be destroyed after the completion of the study. Your name will not be reported with any information you provide. Information you provide will be combined with answers of others and reported in a summary form. The only people that will ever have access to your individual level answers are the researchers at the Urban Institute. All of the research staff at the Urban Institute are committed to privacy and have signed a Privacy Pledge.

Consent for release of protected client data

I authorize [PUBLIC HOUSING AUTHORITY] to give my contact information to the Urban Institute. I authorize the Urban Institute to contact me for an interview as a part of this study, using the information I have provided below.

Signature:_________________________________________ Date: __________________________

[PHA] Staff: ____________________________________________ Date: __________________________

CLIENT CONTACT INFORMATION

(SECTION TO BE COMPLETED BY PHA STAFF ONLY IF CLIENT CONSENTS)

Client Name		Client #
Primary Phone Number		Secondary Phone Number
Primary Address		Secondary Address

 Check here if client declines

QUESTIONS

If you have any questions about the study, you may call Michael Pergamit at the Urban Institute, 1-800-XXX-XXX (toll-free number).

The Paperwork Reduction Act Statement: The described collection of information is voluntary and will be used to evaluate the effectiveness of the Family Unification Program. 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 number and expiration date for the described collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX.