Appendix A. Informed consent form

Appendix A: Informed consent form

OMB No.: XXXX-XXXX

Expiration Date: XX/XX/20XX

Fathers and Continuous Learning in Child Welfare Project

Voluntary Consent to Participate in a Study

[AGENCY] IS PART OF A MULTI-SITE STUDY

[AGENCY]¹ is participating in the Fathers and Continuous Learning in Child Welfare (FCL) Project. This project includes a multi-site study paid for by the U.S. Department of Health and Human Services’ Administration for Children and Families. The U.S. Department of Health and Human Services has asked Mathematica to conduct the study.

You are invited to participate in this important study. Your participation could help improve services for other people like you. Participating is voluntary—the decision is yours. This form describes the next steps if you agree to participate in the study.

WHAT INFORMATION WILL WE ASK FOR TODAY?

• You will participate in a focus group with other study participants. We will ask you questions about your experiences with services and interactions with staff in the [AGENCY]. The focus group will last about 90 minutes. To offset any costs associated with your participation, we will give you a $35 gift card after you complete the interview.

WILL YOUR PRIVACY BE PROTECTED?

• Your name will never be publicly reported. No information that could be used to identify you will be reported in any way. Information you provide will not be shared with [AGENCY].

• All information that is collected about you will be used for research and evaluation purposes only. All information will be kept private and secure, unless the law requires otherwise, or you request release of your information in writing.

• The research is covered by a Certificate of Confidentiality from the National Institutes of Health. This means no one can force the researchers to share information that could identify you, even if a court orders them to share information, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The only exception is that the Certificate does not prevent the researchers from sharing information that would identify you as a participant in the project if you tell the interviewers anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

• A Certificate of Confidentiality does not prevent you from voluntarily releasing information about yourself or your involvement in this research. If you want your research information released to any other person not connected with the research, you must give consent to allow the researchers to release it.

WHAT ARE THE RISKS OF PARTICIPATING IN THE STUDY?

• You might not want to answer some questions. You can refuse to answer those questions. The study team will be very careful to protect all the information in this study, but there is a small risk that non-researchers could see it.

• FCL has been given Institutional Review Board (IRB) approval by Health Media Lab Institutional Review Board. Representatives from the HML IRB may inspect and have access to confidential information because it is their job to ensure your rights as a study participant are protected.

If you have any questions about the FCL study or about your rights as a research participant, you can call the FCL project director, Matthew Stagner, at (312) 994-1044. I will give you a copy of this consent form to take with you when you leave.

Do you agree to participate in this study?

□ YES, I agree to be in this study.

□ NO, I do not want to be in this study.

[IF COLLECTED VIA HARD COPY]

Name (print): ___________________________________________________

Name (sign): _________________________________________________ Today’s date: ­­___________

1 Note to OMB: All fill-in brackets will be customized for each site.