Consent Form - RSS RHP Set-Aside Programs Assessment Guide

[DATE]

Dear [Name],

The Office of Refugee Resettlement (ORR), which is a part of the government that provides funding for some of the services you may have received through the Refugee Support Services (RSS) Refugee Health Promotion (RHP) Set-Aside Program, would like to invite you to participate in an interview to hear about your experience. The purpose of the interview is for ORR to learn more about the experiences of RHP Program participants. Your views will help ORR make improvements to its programs.

Your participation in the interview is voluntary. If you join, you may withdraw at any time during the interview without any impact on your resettlement services. Please note that there are no right or wrong answers to the interview questions. ORR wants to hear many viewpoints and would like you to contribute their thoughts.

If you agree to participate in the interview, you will be asked to join a virtual meeting. If you are selected for a virtual interview, you will need access to a phone or computer in order to join. The meeting will last one hour and will be led by a representative of ORR. Interpretation services will be provided. If you have young children, they are welcome to join you while you participate in this discussion.

With your permission, we will take notes (written and/or on a laptop computer). Please know that your name and other identifying information will not be included in any notes, reports, or publications.

The interview will be scheduled between [DATE] and [DATE]. If you are interested in participating, please complete the consent form below.

Sincerely,

[Insert Name]

Enclosure: Interview Consent Form

Interview Consent Form

I agree to participate in the interview conducted by the Office of Refugee Resettlement (ORR). The purpose of the interview is to learn more about the experiences of YM Program participants. The information collected during the group will be used to help ORR make improvements to its programs.

I understand that my responses will be anonymous and that all information gathered will be kept private. I agree that any information obtained from this interview may be used in reports, provided that I am not identified and my name is not used.

I understand that my participation is voluntary. I may choose not to answer certain questions and may withdraw my participation at any time without penalty. I also understand that my participation, or lack of participation, will not impact my resettlement services in any way.

If I have any questions or concerns regarding this study, I may contact [insert name, phone number, and email for local affiliate contact].

Client Signature

Date

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0970 – 0531. The control number expires on 9/30/2025.