Final 1-18-23-Appendix K_Adult Child Information Release

Family Options Study Adult Child Information Release Form OMB Clearance Number: 2528-0259

Expires: XX/XX/XXXX

Family Options Study

APPENDIX K: ADULT CHILD INFORMATION RELEASE FORM

We are very grateful for your time and cooperation in the Family Options Study. The information you have provided is very useful to the Department of Housing and Urban Development (HUD), researchers and policy makers. Your information provides important information to help families like yours. HUD may want to conduct additional research about the housing and services that are part of this study to see how these kinds of programs could help families who experience homelessness in the future.

We would like to ask for your permission to release your personal information to HUD. If you give your permission Abt will transfer your personally identifiable information securely to HUD. The information we will transfer using secure methods is this:

• full name,

• current address and telephone number,

• Social Security Number, and

• your answers to the questions asked in the online survey to HUD.

At that point, HUD will take responsibility for protecting your information and maintaining its confidentiality. Your answers will be kept separate from your name and other information that can identify you. HUD will use this information only for research. HUD will not use these data to determine your eligibility for any housing assistance or receipt of other benefits.

Part of HUD’s research may include getting information about you from Social Security, welfare, or other government agencies and local homeless assistance providers. Examples of these agencies could include state departments of labor, local school districts, child welfare agencies, and state or other unemployment insurance agencies.

The information will be combined with your survey answers to help HUD understand how families that participated in the Family Options Study are doing now and will help HUD and its researchers learn how different kinds of housing and services helped families who were experiencing homelessness. Only HUD and authorized researchers can see your records. You may still participate in this study if you do not want these records released to HUD. Again, this information will be used only for research, never to determine program eligibility.

Here are some examples of the types of information HUD and other researchers HUD funds may ask for:

• The dates and nature of your participation in shelter, housing, or services programs

• Records of how much money you earned from your state’s department of labor or other earnings data

• Information about receipt of public assistance or disability benefits

• Child welfare records—including dates when you may have been in foster care

• Information about new addresses from any of these sources

• Your school records, including information about how you scored on achievement tests, your school absences, if you repeated a grade, and how you are doing/did in school

• Your records from the criminal justice system, including motor vehicle violations or arrests for other reasons

• Your Medicare or Medicaid records

• Your participation in Temporary Assistance for Needy Families (TANF), Food Stamps (SNAP), or other social programs

I understand that if I agree to allow HUD or other researchers to request this information about me, it means:

1. I understand that HUD researchers may ask for information about me from agencies like those listed above after HUD receives the data.

2. I understand that HUD may send a copy of this form to other agencies to authorize release of my records.

3. I understand that I will sign this form only if I agree to do so. My participation is voluntary. I am NOT required to do this.

4. I understand that if I choose not to sign this form there will be no penalty or loss of benefits I may receive now or in the future.

5. The information from my records will be kept private.

6. I understand that I will not be paid for allowing records to be released to HUD.

7. I will receive a copy of this form.

HUD may also use this information to contact you in the future to see if you would like to participate in additional research. Your participation in any future research HUD or HUD-funded researchers may want to do is strictly voluntary.

If you choose not to participate in the future data collection, there will be no penalty or loss of benefits you may receive now or in the future. If you choose to stop participating in this study, you can do so at any time without any penalty or loss of benefits you may receive now or in the future.

Please look at the two items below and write your initials following the “yes” or “no” for each statement to let us know

if you consent to release the identifiers to HUD for the purposes specified above. 

Yes, I consent____­­­ No, I do not consent____ to release my personal data to HUD.

I have read, or have had read to me, the above description and I have had the chance to ask questions. By signing below or giving my verbal permission, I confirm the decision I have marked above.

/ /

Name of Participant (printed) Signature of Participant Date

COMPLETE IF INTERVIEW COMPLETED BY PHONE:

Verbal Consent Obtained: YES NO DATE:________________________

_____________________________________ __________________________________

Name of Interviewer Signature of Interviewer

Questions About Participation

If you have questions regarding the release of your personal identifiers to HUD or want to withdraw from the study please contact the Survey Director Ms. Brenda Rodriguez at XXX-XXX-XXXX. You may also contact the Abt

Abt Associates Inc. Project Director, Ms. Lauren Dunton at XXX-XXX-XXXX (these are not toll-free numbers). You may also call the study toll-free line at 1-XXX-XXX-XXXX.

If you have any questions about your rights as a participant in this study, you can call the Abt Institutional Review Board, toll free at (877) 520-6835.

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