PACT - ICR - Baseline+MIS - Appendix B - Consent Statement October 19

APPENDIX B

CONSENT STATEMENT

(This will be provided to participants in hard copy by the case worker. Later, during the CATI interview, the consent will be read to the participant, and the participant will acknowledge consent verbally.)

O MB No : 0970-0403

Expiration Date: 10/31/2015

[PROGRAM NAME]

Parents and Children Together (PACT) Study of

Responsible Fatherhood Programs

[PROGRAM NAME]

[Insert program description and specifics about activities and duration.]

[PROGRAM NAME] IS PART OF A NATIONAL STUDY

The [PROGRAM NAME] program is part of the Parents and Children Together (PACT) study, a national study being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about which services help fathers build better relationships with their children and their families, as well as improve their economic stability. The Department of Health and Human Services asked a research team from Mathematica to assist with the study. We invite you to be a part of the study.

WHAT IS THE STUDY ABOUT?

The study is being done to learn how well programs like this work. This program aims to help fathers build better relationships with their children, have healthy interactions with children’s mothers, and get and keep good jobs. This study will determine whether the program achieves those aims, and will help us learn whether there are ways these kinds of programs can be improved.

The [PROGRAM NAME] program is for fathers. If you want to be in the program, you have to agree to be a part of the PACT study. If you decide that you do not want to be a part of the study, you will not be able to participate in the [PROGRAM NAME] program. You will be given information about other services that you can receive in the community.

If you decide to be in the [PROGRAM NAME] program and the study, we will ask you to answer some questions today on the telephone with study staff. We will ask you questions about yourself, your child or children, and their mothers, this will take about 30 minutes. A staff member from the [PROGRAM NAME] program will give you a phone and a private space to use to answer the questions. You will receive $10 in appreciation of your time.

In about 12 months, the researchers will contact you again by phone and ask you questions about topics such as your relationships and interactions with your child or children, your relationship with other family members, your employment, and services you receive. You may also be asked to participate in focus groups, in-person interviews, and to complete check lists about interactions with your child. Researchers may also ask for your permission to interview your child. You will receive an additional payment as a token of appreciation for the time you spend in these activities.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0403. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

he decision to participate in the survey in 12 months, the interviews, and the check lists is voluntary and will have no effect on your participation in the program, and you can decide in 12 months whether to participate in the survey, interviews, and check lists then.

If you agree to be part of the study, it means you are giving permission for the [PROGRAM NAME] program to share information with the study team about the services you receive from the program.

The research team may also contact federal and state agencies for information about your employment and earnings, child support agreements, and criminal background.

HOW WILL PROGRAM PARTICIPANTS BE CHOSEN?

Because the [PROGRAM NAME] program can only serve a limited number of fathers, a computer will randomly select whether or not you can participate in the program. The computer will place you into one of two groups. One of the groups will receive the [PROGRAM NAME] program services at no cost to them. The other group will not receive the [PROGRAM NAME] program services.

The computer works like a flip of a coin—assignment to a group is completely random. This procedure makes sure that assignments to the groups are fair. Everyone who agrees to join the study has the same chance of being placed into either group. The chance of being able to receive services is not influenced by what you say to program staff or your answers to the questions on the telephone. A staff member from [PROGRAM NAME] will let you know if you are assigned to the program group or not after today’s interview.

If you are not randomly assigned to participate in the [PROGRAM NAME] program, you will be provided with information on other services available to you in the community.

At any time, after you have been randomly assigned, you can call our study helpline to say that you no longer want the program to share information about you with the researchers, and that will have no effect on the services available to you.

WILL MY PRIVACY BE PROTECTED?

Everything you tell the program staff or the researchers will be kept strictly private and will not be shared with anyone, except as required by law. However, if a person on the study team observes child abuse, it must be reported as required by law.

The research team will be able to access information you give them and nothing will ever be said about you by name in research reports. Instead, information about you will be combined with information about everybody else in the study, so the researchers can say things like “30 percent of fathers in the program have two children.”

WHAT ARE THE BENEFITS AND RISKS OF PARTICIPATING IN THE STUDY?

Your participation in the study could help in providing services in the future to other fathers like you. There are no known risks of participating in this study, except that you may feel uncomfortable answering some questions in interviews. You can refuse to answer those questions if you wish, and it will not change your participation in the program.

IS MY PARTICIPATION VOLUNTARY?

We hope you will want to be in the study but your participation is strictly voluntary. However, if you do not want to be in the study, you cannot be entered into the computer system to see if you can receive services from [Program Name]. If you agree to be in the study and later decide you do not want to answer some or all study questions or have information from the program shared with researchers, you may decline at any time. If you tell us later you want to withdraw from the study, by consenting to participate in the study, you authorize researchers to use information that was collected about you during the period that you did give permission.

Consent to Participate in Parents and Children Together

I have read the information on the previous pages.

• I have been informed of the services offered by the [PROGRAM NAME] program, and I want to participate in those services.

• I agree to answer a set of questions now. I can choose to participate in later study activities when the researchers contact me in 12 months. I understand that I may be asked some questions about personal subjects, but I will not have to answer any questions that make me feel uncomfortable. I can change my mind about participating at a later time, and this will not affect my participation in the program.

• I give permission for the study team to collect information on [PROGRAM NAME] services I receive. I give permission for [PROGRAM NAME] program staff to release information to the study team about me and my participation in the program.

• I give permission for the researchers to access information about me from federal, state and local agencies about my employment and earnings, child support arrangements and payments, and criminal background.

• I understand that all information will be protected. However, I do understand that if a person on the study team observes child abuse, it must be reported.

• I can call Shawn Marsh toll-free at 1-800-XXX-XXXX at Mathematica Policy Research to get an answer about any questions I may have.

• If I have questions about my rights as a research volunteer, or feel that I have been harmed in any way by participating in the study, I can call (insert NEIRB contact here) from the New England Institutional Review Board, toll-free at 1-800-XXX-XXXX.