SUPPORTING STATEMENT FOR THE
ASSETS FOR INDEPENDENCE (AFI)
PROGRAM EVALUATION
ATTACHMENTS
Office of Planning, Research, and Evaluation
Administration for Children and Families
U.S. Department of Health and Human Services
370 L'Enfant Promenade, SW
Washington, DC 20447
Contract Number HHSP23320095654WC
Order Number HHSP23337032T
August 2012
ATTACHMENT E Informed Consent
Attachment E
Informed Consent
OMB #: 0970-XXXX
Expiration Date: XX/XX/2015
ASSETS FOR INDEPENDENCE (AFI)
PROGRAM EVALUATION
THE PAPERWORK REDUCTION ACT OF 1995: Public reporting burden
for this collection of information is estimated to average 30
minutes for the baseline and follow-up questionnaires, for a total
of 60 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.
Consent form to participate
PURPOSE OF THE EVALUATION
An evaluation study of the Individual Development Account (IDA) program operated by the {FILL SITE NAME} is being conducted by the Urban Institute and RTI International on behalf of the U.S. Department of Health and Human Services. The purpose of this study is to assess the impact of IDAs on the economic well-being of households such as yours. You are one of approximately 1,100 individuals being asked to participate.
SURVEY PROCEDURES
If you agree to participate in the study, you will be asked to complete a 30 minute self-administered survey via computer today and then to complete annual follow-up surveys via telephone for the next three years. The question topics include your employment and financial experiences, housing status and satisfaction, lifestyle and health issues. For each survey that you complete, which will take approximately 30 minutes, you will receive $20 as a token of appreciation.
RANDOM ASSIGNMENT AND IDA BENEFITS
If you decide not to participate in the study, you will need to wait for up to eighteen months before being allowed to apply again for the IDA program at [FILL SITE NAME].
For those who agree to participate in the study, we will use a random assignment procedure (like a lottery) to determine whether or not you are allowed to enter the IDA Program. Each study participant has a 50-50 chance of being allowed to enter the IDA Program, as a member of the study’s “treatment group.” Those not selected to enter the program can still receive any other benefits and services offered by [FILL SITE NAME], as a member of the study’s “control group.” You will be notified of your group assignment at the end of the computer interview today.
If you are selected for the [FILL SITE NAME] IDA Program, you will need to submit financial information, including information from your IDA account at the Bank of [FILL NAME] to the Urban Institute and RTI International for the purpose of this evaluation.
POTENTIAL RISKS AND DISCOMFORTS
In today’s computer questionnaire or in the annual follow-up surveys, you may find some of the questions to be personal. You may refuse to answer any question and you may take a break at any time during an interview.
POTENTIAL BENEFITS
There are no immediate program benefits or services provided to those completing today’s computer survey. For each survey that you complete, you will receive $20 as a token of appreciation. This evaluation may also generate support for government policies that offer resources to households such as yours for investment in long-term economic growth.
PRIVACY
All of the information you provide will be kept private to the extent permitted by law, and we will never publish, release, or share your personal information. Many precautions have been taken to protect your information. Information such as your name and address will be stored separately from the answers you provide on the online survey.
PARTICIPATION AND WITHDRAWAL
Your decision to take part in this study is completely voluntary. You can refuse any part of the program and you can stop participating at any time. You can refuse to answer any question in the computer survey or any follow-up survey. You will not be penalized in any way should you choose not to participate or withdraw. If you have any questions about the project, you may call Melissa Hobbs, the Data Collection Task Leader, at 1-800-334-8571, 25744. If you have any questions about your rights as a study participant, you may call the Administrator of the Institutional Review Board at the Urban Institute, at X (a toll-free number).
By agreeing to participate in this research, you are not giving up any of your legal rights.
The site administrator will record in the computer your decision about participation. We will also provide a copy of this consent form to you for your records.
__________________________________________ _____/____/____
Participant’s Signature Date (mo/day/yr)
__________________________________________
Participant’s Name (first and last name): Please Print
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | OMB Application for |
| Author | mcl2 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |