Attachment 4-Informed Consent for Staff

PROGRAM STAFF INFORMED CONSENT FORM

Before we begin, I want to tell you a few things about this study and your participation in it. Please feel free to ask me any questions you might have. We will also email you a copy of this information.

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 evaluate the FUP program. The FUP program you are affiliated with is one of [NUMBER OF SITES] different sites across the country being included in a rigorous evaluation of the FUP program.

Thank you for agreeing to meet today. I’m going to start the interview by providing an overview of the study. I will then review our informed consent procedures:

• The study focuses on how each of the [NUMBER OF SITES] sites has implemented the FUP program for families involved with the child welfare system.

• We have questions about program design, implementation, and outcomes.

• Your participation in this interview is voluntary and you can choose not to answer any question.

• All the information you provide will be kept private, meaning your individual answers will not be shared with anyone outside the research team working on the study.

• We will not quote you by name in project case studies or reports.

• We do not intend to identify you with any particular statement, but there is the potential due to your role that your comments could be associated with you or your organization. We minimize this potential by combining information from everyone we interview and presenting it in a way that individual answers cannot be easily identified when we report our findings.

• If you agree, we will also record this interview today so that we make sure that we accurately capture the details of everything you tell us. The recording will be used only by the research team and kept secure on a password protected computer drive. Once the project is complete, all recordings will be destroyed. During the discussion, we can also stop the recording if you want to make a particular off-the-record comment.

• Everyone working on the research team has signed a privacy pledge agreeing to these terms.

DO YOU AGREE TO PARTICIPATE IN THE STUDY?

DO WE HAVE YOUR PERMISSION TO USE THE RECORDER?

DO YOU HAVE ANY 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).