PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB

QED Study

Participant Consent form

for program group

Pathway Home Evaluation

November 2022

Participant Consent Form

Agreement to Participate in the
Pathway Home Evaluation

You are invited to be part of the Pathway Home 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 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 (DOL) is working with Mathematica and its partners to conduct this study. The study will compare the outcomes of people who have access to Pathway Home program services to people who do not.

Who can be in the study?

You can be in the study if you are eligible and appropriate for the [PROGRAM NAME] program. Even if you decide not to receive [PROGRAM NAME] program services, you can still be part of the study.

What does it mean to be in the study?

If you choose to be in the study, the study team will collect information about you for up to four years from the following sources:

• Background information form. This form will ask for information about your employment and criminal justice history, as well as personal information like your age, race, and gender. This form will also collect contact information so people will know how to reach you for a follow-up survey. [To thank you for filling out this form, we will provide you with a $15 gift card.]

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

• Interviews and focus groups. The study team may invite you to participate in a one-hour focus group while you are incarcerated. [To thank you for your participation in the focus group, we will provide you with a $20 gift card.] The study team might also ask to interview you after your release from incarceration. The interview will take approximately one hour. To thank you for your participation in that interview, we will provide you with a $50 gift card. You do not have to participate in the interview or focus group or answer any questions that make you uncomfortable.

• Program and government records. The study team will access some information about your employment, earnings, and criminal justice involvement from government records. Government records might include those obtained from agencies such as the U.S. Department of Health and Human Services, State Departments of Corrections, State Departments of Justice, State Administrative Offices of the Courts, and local Sheriff’s Departments or Jail Administrator Offices. You won’t need to do anything to make this happen.

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 who have been incarcerated. You will also receive a gift card as a ‘thank you’ for each study activity you complete

The risks are small. The study team will follow laws that require us to keep private all information that could be used to identify you (like Social Security Numbers). We will also remove all such information, including your name and contact information, from data that we provide to DOL. There is a small risk that your information may be leaked; however, we will take very strong precautions to prevent this from happening.

Do I have to be in the study?

No. The decision to be in the study is your choice, but you must be in the study to receive [PROGRAM NAME] 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 may still 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 Evaluation.

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

• 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 the study team might contact my probation or parole officer to get current contact information so they can invite me to participate in the survey.

• 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 PHEvaluation@mathematica-mpr.com or call 1-844-990-1303. You may also contact Monica Mean at the U.S. Department of Labor (202-693-6034; mean.monica@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 (1-202-246-8504; www.healthmedialabirb.com).

The OMB control number for this collection is 1290-0039 and expires on 8/31/2025. 

According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number. Collection of this information is authorized by Section 169 of the Workforce Innovation and Opportunity Act (WIOA). The obligation to respond to this collection is voluntary. We estimate it takes about 5 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information.  Please send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Chief Evaluation Office, 200 Constitution Ave NW, Washington, DC 20210, or email ChiefEvaluationOffice@dol.gov and reference OMB control number 1290-0039.