Baseline Consent Form

Participant Consent Form

Agreement to Participate in the
Pathway Home Grant Program Evaluation

You are invited to be part of the Pathway Home Grant Program Evaluation. This form explains what it means to be in the study. To join the study, sign your name at the end of the form.

What is the Pathway Home Grant Program Evaluation?

It is a study to learn how the [PROGRAM NAME] program, a Pathway Home program, helps the people it serves. The U.S. Department of Labor contracted with a third-party evaluator to conduct this study. The study will compare the differences between those that have access to Pathway Home program services and those who do not.

Who can be in the study?

Every volunteer who is eligible and appropriate for the [PROGRAM NAME] program can be in the study.

What does it mean to be in the study?

Because more people want [PROGRAM NAME] program services than the [PROGRAM NAME] can serve, and because the research team plans to study the ways in which these services help improve participants’ lives, we will use a lottery to select who gets into the treatment group and can receive [PROGRAM NAME] services. If you are not selected, you can still be a part of the study but you will not be able to receive Pathway Home services for a period of 2 years. All eligible applicants have an equal chance of getting into the treatment group. The selection is random and it has nothing to do with your age, race, gender, criminal history, or anything else about you.

The study team will collect information on you for up to four years.

• Background information. Some information about your employment and criminal justice history as well as demographic and contact information.

• Follow-up survey. The study team will ask you to complete a follow-up survey 12 to 15 months after your enrollment in the study. The survey will ask questions about your receipt of program services and outcomes related to employment. To thank you for your participation, we will provide you with a $25 gift card.

• Interviews and focus groups. Some information will come from you. The study team may ask to interview you about one or two years after you enroll in the study. The interview will take approximately one hour. To thank you for your participation, we will provide you with a $50 gift card. The study team may also invite you to participate in a one-hour focus group. You do not have to participate in the interview or focus group or answer any questions that make you uncomfortable.

• Program and government records. Other information will come from records about you. These records may include information from [PROGRAM NAME] about your program activities. They may also include information at local, state and federal government agencies about your employment and earnings and information from the criminal justice systems.

How will the study use your information?

The study team will use your information for research purposes only. The team will follow strict rules to protect your privacy and keep your information private. Your name will never be used in any report written for the project. The government may see your information if it audits us.

What are the benefits and risks of participating in the study?

You will help [PROGRAM NAME] and other programs learn how to provide better services for people like you.

The risks are small. Even if you are not selected to receive [PROGRAM NAME] program services, you can still be part of the study and access other services in your community. The study team will follow strict rules to keep your data private. Personally identifying information such as Social Security Numbers will be kept private to the extent permitted by law. Furthermore, your name and contact information will be removed from data before we provide any results to DOL. There is a small risk of a breach of privacy; however, strong precautions will be taken to protect your information.

Do I have to be in the study?

No. The decision to be in the study is your choice. However, only people who are in the study will have a chance to receive [PROGRAM NAME] program services. You may drop out of the study at any time by contacting the study team (see contact information below). If you drop out, the study team still may use the information collected while you were in the study.

Statement

• I have read this form and understand the information presented.

• I agree to be in the Pathway Home Grant Program Evaluation.

• I know the decision to be in the study is my choice.

• I know that I will have a chance to receive [PROGRAM NAME] program services. If I am not selected, I will not be able to receive Pathway Home services for 2 years.

• I understand I can drop out of the study at any time.

• I know that the study team will follow strict rules to protect my privacy. My name will never appear in any public document.

• I understand that the study team will get information about me. The information will come from programs and government agencies, as described above.

• I understand that I may be contacted to take part in a survey or focus group. I know I do not have to participate or answer any questions that make me uncomfortable.

___________________________________________

Applicant Date of Birth (e.g. 01/01/1995)

Name of Applicant (Please Print)

Signature of Applicant

_______________________

Date

Questions about the Pathway Home Grant Program Evaluation? Please contact a member of the Mathematica study team at XXX@mathematica-mpr.com or call 1-888-XXX-XXXX. You may also contact Jessica Lohmann at the U.S. Department of Labor (1-202-693-5087; lohmann.jessica@dol.gov). If you have any questions about your rights as a study participant or other questions, concerns or complaints about the study, you may contact the Health Media Lab Institutional Review Board (1-202-753-5040; www.healthmedialabirb.com).