Final - Consent_Agreement

Consent Form
Equitable Engagement at HUD

Consent to Participate
You are invited to participate in conversations with the Department of Housing and
Urban Development (HUD) to share your valuable perspectives on credit and
homeownership and help HUD address housing inequities.
OMB Control Number: 2511-0001
Expiration Date: 09/30/2024
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number. The time required to complete this information collection
is estimated to average 5 minutes. All responses to this collection of information are voluntary. If you have comments
or concerns regarding this collection, please contact Helen Nicholas of HUD’s Customer Experience team at
helen.e.nicholas@hud.gov.

Overview
What is this project? HUD wants to support fair and impartial opportunities for
homeownership. To do this, HUD is seeking out diverse perspectives around credit and
homeownership and aims to speak directly to people with lived experiences. We hope
you will consider taking part in this outreach.
What will I be asked to do? We will ask you to set aside one hour to share your
experiences and perspectives about homeownership and credit.
Will you record what I say? We would like to audio record the session, but we will only
do this if you agree to it. If you are not comfortable with us recording the session, we will
take notes on a computer.
What are the benefits of participating? Taking part in this conversation will not benefit
you personally but will help HUD better serve people in the future. By participating, HUD
can better understand the needs of the people it serves and work to improve programs
and services.
Will I receive money or an incentive for participating? You will not receive money or
an incentive for participating in this conversation.
How will you use the information you gather from me and how will that
information be shared? Anything you share during our conversation will only be
shared internally within HUD, and will not be reported on publicly. We will disconnect
your identity with anything you share with us before sharing with anyone else within

Consent Form
Equitable Engagement at HUD

HUD. After making your feedback anonymous, we will review what you and others
share with us. We will sum up feedback into common pain points or bright spots that
people experience around credit and homeownership. These experiences and
perspectives will be shared internally. We respect your privacy -- we will never use your
real name in any reports and will work to avoid details that might make it obvious that
we are talking about you. See the following two questions and answers for more details.
Will you share my name? We will not use your real name in any of our materials. Your
real name will be stored temporarily in a secure location so we can schedule a
conversation with you. Only those responsible for scheduling and facilitating your
conversation will have access. We will store any documents with your real name in a
location separate from our project materials, so that your real name is not connected to
any information that we share. Additionally, your real name will be removed from these
documents two weeks after we speak with you.
Will you share other personal information about me? Yes, with your permission, we
will. In any of our internal discussions or presentations, we may say “Leslie (made-up
name) is a man in his 30’s who lives in Texas.” We will use a made-up name to refer to
you in any of our materials. With your permission, we may also share details about your
experience with a government service and your perspective around it. For example,
“Leslie works to figure out if people are eligible for government benefits for people
who’ve purchased cars that have bad tires that have been recalled.” We may share
more than one detail about your experience from our conversation. We will work to
avoid details that make it obvious that we are talking about you. But it is possible that
someone who knows you well could recognize details we describe and identify you as
one of our participants. However, this material will only be shared within HUD.
What are my rights as a participant in this conversation? Your participation is
entirely voluntary. If at any time you do not feel comfortable answering a question,
simply say you’d like to move to the next question. We’ll then move on to the next
question. If at any time you would like to end the conversation, you may do so.
Who can I contact about this project and my participation in it? If you have
questions, please reach out to [Insert Contact] at [insert email]. Make sure to ask your
questions before completing this form.
What if I am unable to submit the consent online before the our conversation? If
for any reason you are unable to submit this form online, we will review the form
verbally with you during our conversation and you have the option to provide verbal
consent.

Consent Form
Equitable Engagement at HUD

Consent Agreement
Consent to Use of Possible Identifying Information and Quotes
I have read the above details and have had my questions answered about taking part in
this outreach effort.
* Required
I agree to take part in a conversation with representatives of HUD. *
_______(Initial/Check) Yes
_______(Initial/Check) No

I agree to my quotes and experiences being included in presentation to HUD
employees about this topic. I understand my real name will not be connected to
any quotes or experiences. *
_______(Initial/Check) Yes
_______(Initial/Check) No

I agree to be audio recorded. *
_______(Initial/Check) Yes
_______(Initial/Check) No

________________________________________________ *
(Participant’s Name printed)

________________________________________________ *
(Participant’s Signature) (Date)