B. TLP Parental Consent Form - Outcomes Study - REVISED

OMB Control No: 0970-0383

Expiration Date: 09/30/2021

Parent or Legal Guardian Permission Form for Child’s Participation in the Youth Outcomes Study

The Youth Outcomes Study (YOS) is a study about the experiences and outcomes of young adults who enrolled in a Transitional Living Program (TLP) or Maternity Group Home (MGH). A company called Abt Associates runs the study. The Administration for Children and Families in the U.S. Department of Health and Human Services is paying for it. This form gives information about the study and your child’s role as a study participant. Your child’s participation will help the research team learn more about the benefits of programs like <<Name of TLP/MGH>>. At the end of the form, you can tell us whether you want your child to be in the study. It is important that you read the entire form.

What does it mean for your child to be in the study?

Being in the study is completely up to you and your child. You both get to decide if your child wants to be in the study or not. Your child can also decide to quit the study at any time. If your child decides to leave the study in the future, it is okay. Leaving the study will not harm them in any way or affect their eligibility for any other services here or elsewhere.

If you and your child agree for your child to be in the study, the research team will collect some information about your child.

1. The researchers will ask your child to complete a short intake form today. Your child will be asked to provide their name, date of birth, Social Security Number, and other demographic information. The form will also ask your child whether they or their family have ever received public assistance, and how the COVID-19 crisis has impacted your child. Your child will receive a $10 electronic gift card to Amazon.com as a thank you for completing this form.

2. The researchers will use your child’s name, date of birth, and/or Social Security Number for up to five years to collect data on him or her. This will include information about your child’s employment and earnings from the National Directory of New Hires or similar records. It will also include information about your child’s participation in education and training from the National Student Clearinghouse. This may include information such as course enrollment, credits earned, and completion and degrees or certificates earned.

3. The researchers will collect information that <<Name of TLP/MGH>> collects about your child. This will include verifying your child’s Social Security Number. It will also include the dates your child entered and exited the program, your child’s exit destination, your child’s housing status after exiting the program, and how the COVID-19 crisis impacted your child's TLP or MGH program services.

4. The researchers may ask your child to participate in an interview or a focus group to talk about your child’s experiences with the TLP or MGH program.

What are the possible benefits and risks if my child agrees to participate in the study?

By being in the study, your child will help the researchers learn more about how TLP and MGH programs help young adults with housing, education, and employment. The information learned from the study is intended to improve services for people like your child.

There is very little risk for your child to participate in this study. The researchers will keep your child’s personal information private, as much as the law allows. There is a small risk of a loss of privacy. However, the researchers have many safety measures to prevent this from happening. Any computer files with your child’s name will be stored on a secure network that is protected by a password.

Your child’s name will never be used in any public document or data file created as part of the study. Up to 400 people will be in this study. When the researchers write a report, your child’s information will be combined with information from all the other people in the study. At the end of the study, a data file with “anonymous” versions of study participants’ data may be made available to the funder of the study and authorized researchers. The data in that file will not identify your child individually.

To help protect your child’s privacy, the research team has received a Certificate of Confidentiality. The certificate is issued by the National Institutes of Health. It adds special protection to your child’s data. It is important to understand what the Certificate can and cannot do. Because the research team has this Certificate, it can:

(1) legally refuse to give information that may identify your child in any federal, state, or local proceedings. This includes if there is a court subpoena.

(2) resist any demands for information that would identify your child.

Because of the Certificate, the researchers do not have to tell anyone who your child is or that they are in the study.

However, even with the Certificate, the researchers may:

(1) tell state or local authorities if they find out that your child or someone else could be hurt or in danger.

(2) not resist a request from the study’s funder to view the study data to audit the project or evaluate the program.

The Certificate does not prevent you, your child, or your family from telling someone about your child’s involvement in this research. If your child requests in writing that they want someone to get their research information then the researchers will not withhold it.

Who should I contact if I have any questions about the study?

If you have any questions about the study, contact the researchers at 855-857-3364 (toll-free call) or YOS@abtassoc.com. You can also contact Alisa Santucci, Abt Associates Study Director. You can call her at 301-347-5376 (toll call) or email her at Alisa_Santucci@abtassoc.com. For questions about your child’s rights in the study, contact Katie Speanburg at Abt Associates. You can call her at 877-520-6835 (toll-free call) or email her at IRB@abtassoc.com.

Permission to Participate

This agreement is effective from the date you sign it until the end of the Youth Outcomes Study. If your child chooses to quit the study, this agreement will end at that time. Your child may choose to quit the study at any time. If your child does quit the study, researchers will continue to use information collected during the time before they quit. To quit the study, please call the researchers toll-free at 855-857-3364.

Permission: Here, you tell us if you agree to allow your child to be in the study. Please read this carefully and ask a staff member if you have any questions about what you are agreeing to.

Please select one:

 Yes, I agree to allow my child ____________________________(print child’s name) to be in the Youth Outcomes Study as described above.

 No, I do not agree to allow my child ________________________(print child’s name) to be in the Youth Outcomes Study.

To confirm your selection, please print your full legal name and date where indicated below.

First Name: ____________________________

Middle Name (leave blank if you do not have a middle name): __________

Last Name: ____________________________

Date: _________________

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of the described voluntary collection of information is estimated to average 0.25 hours per youth response. 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.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Alisa Santucci, Abt Associates, 6130 Executive Blvd, Rockville, MD 20852; Attn: OMB-PRA 0970-0383.

TLP YOS: Parental Permission Form Page 1