Implementation Drivers Web Survey consent 7-19-12

OMB No:

EXPIRATION DATE:

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 3 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.

PERMANENCY INNOVATIONS INITIATIVE

IMPLEMENTATION DRIVERS ASSESSMENT SURVEY

CONSENT

Westat and its subcontractors, James Bell Associates, the School of Social Work of the University of North Carolina at Chapel Hill, Andrew Barclay Associates, and Ronna Cook Associates have been contracted by the Administration for Children and Families, Office of Planning, Research, and Evaluation, to evaluate the Permanency Innovations Initiative (PII). The survey is designed to help assess progress towards implementation as well as to test the relationship between the achievement of implementation components and progress towards full implementation.          

The survey should take approximately 45 minutes to complete. We anticipate no risk or harm to you by completing this survey and the information will benefit the process evaluation for PII.         

Completion of the survey is voluntary and participation can be discontinued or questions skipped at any point during the survey without risk of penalty. The information gathered will be used in aggregate to inform the implementation component of the evaluation.          

The survey is private to the extent permitted by law. Your name will not be used or appear in any reports and in any files used for analysis. The data collected will be stored on a secure server and will be accessible to select research team members for analysis and quality assurance purposes.          

If you have any questions related to the survey itself, you may contact the survey manager, Leslie Cohen at cohen@jbassoc.com or 312-342-1397. If you have any general questions about the PII evaluation, you may contact the associate project director, George Gabel, at georgegabel@westat.com or 301-251-4223.  If you have any questions regarding your rights as a participant, you may contact Sharon Zack, Westat Institutional Review Board (IRB) Administrator at 1-800-WESTAT1 (937-8281), x8828 or at SharonZack@westat.com.   

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number.               

Please check the appropriate box and sign below to indicate that you agree to complete the survey. Please print a copy for your records.         

Subject Statement: I agree to participate in the survey that will include questions about implementation drivers and understand what completing the survey involves and that participation is voluntary.  

I am willing to participate in the survey. Checking "yes" will indicate consent.

• Yes

• No