Consent for Assessment

OMB Clearance Number: 2528-0337

Expires: XX/XX/XXXX

Attachment C: The Home Assessment Consent

If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing XXXX@XXXX.XXX. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.

 

Paperwork Reduction Act Burden Statement 

This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at XXXX@XXXXX.XXX or call XXX-XXX-XXXX.  

 

Privacy Act Statement  

Authority:  Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  Evaluation of the Community Choice Demonstration (CCD).  

Routine Use:  The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.  

Disclosure:  Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals. 

SORN ID:  Community Choice Demonstration Evaluation Data Files, HUD/PDR-09  

A few weeks ago, you agreed to take part in a study sponsored by The US Department of Housing and Urban Development (HUD) called the Community Choice Demonstration. We would now like to invite you to participate in one of the study activities called the Home Assessment. The Home Assessment is optional. Abt Associates, an independent research company, will be helping with this Assessment.

The Home Assessment tries to understand if neighborhood conditions affect your home’s air quality. The Assessment will be done in the homes of people who have a Housing Choice Voucher and participate in the Community Choice Demonstration.

The Home Assessment includes three parts:

• Direct measurements of pest allergens and indoor air quality in the home. The interviewer from Abt will use a small device to measure some things in your home. The things are:

  • temperature and humidity

  • carbon dioxide

  • carbon monoxide

  • mouse and cockroach allergens

  • tiny pieces of solids or liquids that are in the air called “particulate matter”

  • Chemicals that get into the air from things like paint and cleaner. These are called “volatile organic compounds” or “VOCs”.
    
    

The interviewer will measure these things 5 times in different parts of your home and once outside your home. The interviewer will also measure mouse and cockroach allergens in one room in your home.

• Observations by the interviewer. The interviewer will use a checklist to look for risk factors for asthma and other breathing conditions in your home. The checklist is focused mainly on things that are known to contribute to asthma or other breathing conditions, like mold. It also includes a small number of other items related to the quality and safety of your home. The interviewer will not be looking at other details of your home.

• Short survey. The interviewer will ask you to complete a short survey. The survey will be about things that might put people at risk for asthma and other breathing conditions and child health conditions. The survey will also collect information about whether there is smoking in and around the home.

Interviewers will collect information from you two times. The first time is today. The second time is around this time next year. You will receive $45 for participating in the Home Assessment activities today and $50 for participating in the follow-up assessment about one year from now. That is a total of $95.

Do I have to participate?

No. Your participation in this study is completely voluntary. You can choose not to answer any question. You can stop the assessment at any time. Your housing assistance will not be affected if you do not participate in the Home Assessment. If you choose to not take part in the Home Assessment, you will still be part of the original Community Choice Demonstration study. There are no financial costs to you for taking part in this study.

Who will see the information provided?

Any information that the researchers collect will be kept confidential and protected as required by the Privacy Act.¹ Special efforts have been taken to protect your privacy and to make sure that any confidential information is not accidentally disclosed. But if we see or hear that someone may be at risk of harm, we may need to tell the authorities.

Reports for this study will only show summaries. The reports will not have any names or ways to identify a person.

Your information like your name, contact information, and the results of the interview and measurements will only be available to the following people:

• the interviewer conducting this survey,

• the study team members who will analyze the information,

• a small number of HUD staff authorized to work on the study,

• other HUD approved researchers that may work on this study in the future, and

• people that work at the lab that processes the sample measurements.

Anyone given access to the data has a legal responsibility to keep your information confidential.

Are there any risks to me participating in this study?

There are minimal risks to you from taking part in these activities. The study has strict rules in place to protect the information you provide as we mentioned above. We have made special efforts to protect your privacy. However, there is some risk that your information could be released accidentally to people other than the researchers doing this study. If that were to happen, we would contact you to let you know that this happened.

There are no direct personal benefits to you for participating in the study. You will be provided with a gift card to thank you for your time. Some people also find it beneficial to know that they are helping others by contributing to this research.

Questions About Participation

If you have questions about this study, please contact the Survey Director XX at XXX-XXX-XXX. You may also contact the Abt Associates Inc. Project Director, XXX at XXX-XXX-XXXX. (These are not toll-free numbers). You may also call the study toll-free line at XXX-XXX-XXX.

If you have any questions about your rights as a participant in this study, you can call the Abt Associates Institutional Review Board (IRB), toll free at XXX-XXX-XXX.

I have read the above information, or had the document read to me. I understand that my participation in Home Assessment is entirely voluntary and that I can refuse to answer any question or stop being in the study at any time. I agree all information about me will be kept private unless doing so would put me or someone else in danger. I consent to the data collection as described above, for as long as the study is ongoing. I agree that a copy of this consent form will be given to me to keep for my records.

____ Yes, I agree to be part of the Home Assessment.

Enter your name: __________________________________

Signature: __________________________________ Date: __________

1 Privacy Act Statement: HUD’s authoritative and principal purpose, conditions of uses, and impacts, if any, for not participating in the survey are referenced within the participant agreement. HUD’s statutory authority for collecting this data can be found at Section 502 (g) of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. 1701z-1; 1701z-2(d) and (g)).