Attachment A-15. MI Practitioner Focus Group Consent

Attachment A-16. Consent to Participate in Focus Group with MI Practitioners

BEYOND BENEFITS STUDY
SOCIAL SECURITY ADMINISTRATION

Consent to Participate in Focus Group with Motivational Interview
Practitioners
What is the purpose of the study?
The Social Security Administration (SSA) is conducting the Beyond Benefits Study to collect information about
the service, medical and employment needs of working-age adults who currently receive disability-related
payments or stopped receiving disability-related payments from SSA due to medical improvement. SSA hired
Westat, a national research company, to carry out the study. The purpose of the research is to help SSA identify
ways to help people who may be leaving or have left SSA disability benefit programs.
What we are asking of you
We seek your consent for your voluntary participation in an approximately one-hour focus group with other
motivational interview practitioners. We will ask about your experience with motivational interviewing,
challenges and benefits of motivational interviewing with different populations and other work-related topics.
We will schedule it at your convenience between [TIME FRAME]. The interview will take place via a video call.
We will ask for your permission to send text message reminders about the study. Depending on your texting
plan, you may incur a charge for these texts. If you agree, you will be able to opt-out of receiving these
reminders at any time by replying “STOP” to the text or by calling the Help Desk at Westat. 1
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We ask for your permission to audio record the focus group so we accurately capture what you tell us. If at any
point you do not wish to be audio-recorded, the focus group facilitator will give you permission to leave the
focus group. The recording will be used to develop the report and will be destroyed once the study is
completed. The report will not contain information that could identify you. If you decide not to volunteer, it
will not affect any decision SSA makes about your current, or future, disability benefits or payments.
What benefits will you get for participating?
You will not benefit directly from participation. By participating in this study, you will contribute to SSA’s
understanding of policies and programs that might be helpful to people who leave disability programs. After
completing the focus group, we will mail you a $40 Visa gift card.
Persons eligible for participation in the study.
You were randomly selected to participate in the study from a list motivational interview practitioners. Everyone
on the list had the same chance of being selected.
What is the study doing to minimize your risks?
There is a small risk of disclosure of your personal information. To reduce this risk, we will separate any
information that identifies you from the rest of your data and store those identifiers separately. Although it is
not likely, it is possible that some of the questions may be sensitive. If this happens, you can skip the questions
or stop participating. If you get upset, you may request a referral to crisis management services. It is your
decision to use this referral.
How will we protect your privacy?
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Each text message sent by the study will also include these opt-out instructions.

Attachment A-16. Consent to Participate in Focus Group with MI Practitioners

We will follow Federal law and regulations to protect your privacy. SSA and Westat will protect your personal
information collected during the study. The information we collect is used for research in limited ways,
consistent with applicable Federal law, regulations, and directives. For example, we use your thoughts and
comments about motivational interviewing, combined with thoughts and comments about motivational
interviews from other focus group participants, to understand motivational interviewing needs. Your name or
other identifying information will not be included in any published reports.
Privacy Act Statement Collection and Use of Personal Information. Section 1110(a) of the Social Security
Act, as amended, allows us to collect this information, which we will use to help the Social Security
Administration (SSA) identify ways to help people who may be leaving or have left disability programs.
Providing us this information is voluntary; not providing all or part of the information will not affect your SSA
benefit. As law permits, we may use and share the information you submit, including with other Federal
agencies, contractors, student volunteers, and others, as outlined in the routine uses within System of Records
Notice (SORN) 60-0218, available at www.ssa.gov/privacy. The information you submit may also be used in
computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts
under these programs.
Who you can contact if you have questions?
For questions about the study, call the study’s toll-free number at 1-855-516-3665. For questions about your
rights and welfare as a research participant, call the Westat Human Subjects Protections office at 1-888-9207631. Leave a message only with your first name, the name of the research study (Beyond Benefits Study) and a
phone number beginning with the area code, please do not leave any other personal information in the message.