Appendix A – Listening Session Consent Form

P articipant Release Form

LISTENING SESSION CONSENT

As part of my participation in the Listening Session with Fathers and Families Living in Rural Pennsylvania, and the Outskirts of Urban and Suburban Communities, I understand participation is voluntary, and that I may cease participation at any time. I acknowledge that my participation is private. Reports about the listening session will protect participant’s privacy by excluding names and personally identifiable information. I understand that there will be an audio recording to create a transcript and analyze the information provided by participants.

I agree to participate in the listening session: Yes___ No___

Print Name _________________________________

Signature ___________________________________

Date _______________________________________

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: Public reporting burden for the described collection of information is estimated to average 1.5 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0690 and the expiration date is 3/31/2027. If you have any comments on this collection of information, please contact Chad Sawyer by email at chad.sawyer@acf.hhs.gov.