Attachment B. Informed Consent Forms

Attachment B: Informed Consent Forms

The informed consent forms for the random assignment and non-random assignment grantees are included here respectively.

AGREEMENT TO TAKE PART IN THE

HEALTH PROFESSION OPPORTUNITY GRANTS PROGRAM AND STUDY

The Health Profession Opportunity Grants (HPOG) Program is a job training program funded by the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) in Washington, DC. The HPOG program is intended to help people improve their skills, find jobs, and advance in healthcare careers. Our local program, [name of HPOG program], receives funding from this national HPOG program.

HHS is also funding research to study how well our program works in helping people get training and jobs, including the Next Generation of HPOG Programs Impact Study (Next Gen HPOG Impact Study). Over the next several years, researchers will be using information about people in the program to do their studies. This form: 1) describes the research study and 2) requests your participation in the study. We need to tell you about the study and what it means to be part of it. Only individuals who agree to participate in the study will be able to enroll in our [name of HPOG program] HPOG program.

Research Overview

The Next Generation of HPOG Programs Impact Study (Next Gen HPOG Impact Study). For up to five years, [name of local HPOG program] will be in the Next Gen HPOG Impact Study. The study will assess if and how HPOG makes a difference in people’s lives by helping them complete training and get healthcare jobs. The study also will help the government learn how to improve the HPOG program, and similar programs, in the future.

What does it mean to be part of the study? As part of the impact study:

1. The study team will collect data from all eligible applicants of the [name of HPOG program] program when they are first applying to the program.

2. During the period of the impact study, entry into the HPOG program will be by lottery. If you are an eligible applicant for [name of HPOG program], you will take part in a lottery to see if you will be invited to participate in [name of HPOG program]. Some applicants may be invited to enroll in an “enhanced HPOG program (slightly different from the regular HPOG program in that it offers additional “enhanced” services), as well. If you are not invited to participate, you will not be able to enroll in [name of HPOG program]. However, you can enroll in any other service or program for which you are eligible.

3. The study team will collect follow-up information from people who enrolled in the [name of HPOG program] program, people enrolled in the “enhanced” HPOG program (if applicable), and people who were not invited to enroll in the program. This follow-up will include collecting updated contact information about every four months and then more detailed follow-up surveys will likely happen fifteen months and three years after people have applied to [name of HPOG program]).

We expect up to 52,500 people at 35 HPOG grantees to participate in the Next Gen HPOG Impact Study. Participation in this study is voluntary. If you choose not to be a part of this study, you will not be able to participate in the lottery for the HPOG program. You can, however, enroll in any other service or program for which you are eligible.

What type of information will the study collect? The researchers need your permission to get information about you so they can understand the types of people in the program and how well the program is working. For the impact study, researchers want:

1. Information you provide [name of HPOG program] when you first apply to the program including:

   1. Current information about you, your family, your education, and your work history; and

   2. If you have children, researchers would like to request information about their birthdates and names. Researchers may also contact you in the future about including your children in a related study. You can participate in this study even if you do not want your children to participate in another future study.

2. If you are invited to participate in [name of HPOG program] or the enhanced HPOG program, information you or other organizations provide to program staff about the training and services you get while you are in the program.

3. Information from follow-up surveys, including:

   1. Updated information about you, your family, your education, and your work history;

   2. Information about the training and services you get in the program or information about training and services you get outside the program if you are not in the HPOG program;

   3. If you have children, updated information on your children including their experiences at home and school. You can participate in this study even if you choose later not to answer questions about your children in another future study; and

   4. Updated contact information every four months or so to make sure the study team knows the best way to reach you.

4. Personal data such as your Social Security number so they can get information from government sources about your future employment, earnings, and education.

You may refuse to answer any specific question about yourself or your children at any time, but we encourage you to answer the questions. By participating in this study, you will help the federal government and programs around the country learn about the best way to provide training and help people get a healthcare job.

Will my information be kept private? Researchers will use data security procedures to keep all of the study data private and to protect your personal information. All of the information used in research will be kept private to the extent allowed by law. However, there is a small risk of a breach of privacy. Strong precautions will be taken to make sure this does not happen. Your name will never appear in any report or with any research findings. The researchers will combine the information about everyone in the program to analyze how the program helps people improve their skills, find jobs, and advance in healthcare careers. Any forms or other papers that include your name will be kept in a locked storage area. Any computer files with your name will be locked and protected. Any researchers using information to study the program must follow all data security procedures and sign a privacy agreement.

Requesting Your Permission

This agreement is effective from the date you sign it (shown below) until the end of HHS’s research on the next generation of HPOG grants, or when you choose to withdraw permission. You may choose to withdraw your participation at any time. If you do withdraw, researchers will continue to use information collected during the time you consented. To withdraw from the study, please contact someone at the [name of HPOG program].

You will receive a copy of this form for your records. An agency may not conduct and a person is not required to respond to an information collection request unless it displays a currently valid OMB control number.

For questions or concerns about your rights as a research participant, call Teresa Doksum at the Abt Associates Institutional Review Board at toll-free 877-520-6835. For questions or concerns about the research, call [XXX] at XXX-XXX-XXXX.

Statement

“I have read this form and agree to allow information about me to be used in the Next Generation of HPOG Programs Impact Study and in other HPOG research studies. I know that my participation in the research study is voluntary, that researchers will use data security procedures to keep all of the study information private as described above, and that my name will never appear in any public report. I know that I can refuse to answer any questions researchers might ask me, and that I can stop being included in the research at any time without penalty. I understand that researchers will use my personal information to get information about me from other sources, as described above.”

Print Name of Study Participant

If you agree to let Researchers use your information, sign above date

If You Do Not Agree to Let Researchers Use Your Information, Sign Above Date

Parent or Guardian for HPOG applicants under the age of 18, your parent or legal guardian also must sign below:

Print Name of Parent/Guardian

If you agree to let researchers use your Child’s information, sign above date

If You Do Not Agree to Let Researchers Use Your Child’s Information, Sign Above Date

AGREEMENT TO TAKE PART IN THE

HEALTH PROFESSION OPPORTUNITY GRANTS PROGRAM AND STUDY

The Health Profession Opportunity Grants (HPOG) Program is a job training program funded by the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) in Washington, DC. The HPOG program is intended to help people improve their skills, find jobs, and advance in healthcare careers. Our local program, [name of HPOG program], receives funding from this national HPOG program. HHS is also funding research to study how well our program works in helping people get training and jobs.

Research Overview

Over the next several years, researchers will be using information about people in the program to do their studies. By participating in the studies, you will help us, the federal government, and programs around the country learn about the best way to provide training and help participants get a healthcare job. You will be asked for information at certain times during your participation in the program and after you leave the program. You may be contacted by a researcher after you leave the program to answer some questions about your experiences. While we encourage you to answer their questions, you may refuse to answer them.

What type of information will the studies collect? The researchers need your permission to get information about you so they can understand the types of people in the program and how well the program is working. For the research studies, researchers want:

1. Information you provide [name of HPOG program] when you first apply to the program including current information about you, your family, your education, and your work history;

2. If you have children, researchers would like to request information about their birthdates and names. Researchers may also contact you in the future about including your children in a related study. You can participate in research studies even if you do not want your children to participate in future studies.

3. Information you provide to [name of HPOG program] about the training and services you get while you are in the program; and

4. Personal data such as your Social Security number so they can get information from government sources about your future employment, earnings, and education.

Participating in research studies is voluntary. You may withdraw your permission to share data at any time. Refusing to provide permission for research now, or withdrawing permission for research later, will not affect your eligibility for any services in this program or elsewhere. If you withdraw, researchers may continue to use information that was collected about you during the period that you did give permission for research.

Will my information be kept private? Researchers will use data security procedures to keep all of the study data private and to protect your personal information. All of the information used in research will be kept private to the extent allowed by law. However, there is a small risk of a breach of privacy. Strong precautions will be taken to make sure this does not happen. Your name will never appear in any report or with any research findings. The researchers will combine the information about everyone in the program to analyze how the program helps people improve their skills, find jobs, and advance in healthcare careers. Any forms or other papers that include your name will be kept in a locked storage area, and any computer files with your name will be locked and protected. Any researchers using information to study the program must follow all data security procedures and sign a privacy agreement.

Requesting Your Permission

This agreement is effective from the date you sign it (shown below) until the end of HHS’s research on the next generation of HPOG grants, or when you choose to withdraw permission. You will receive a copy of this form for your records. An agency may not conduct and a person is not required to respond to an information collection request unless it displays a currently valid OMB control number.

For questions or concerns about your rights as a research participant, call Teresa Doksum at the Abt Associates Institutional Review Board at toll-free 877-520-6835. For questions or concerns about the research, call [XXX] at XXX-XXX-XXXX (toll free).

Statement

“I have read this form and agree to allow information about me to be used in the Health Profession Opportunity Grants Program Next Generation research studies. I know that my participation in the research study is voluntary, that researchers will use data security procedures to keep all of the study information private as described above, and that my name will never appear in any public report. I know that I can refuse to answer any questions researchers might ask me, and that I can stop being included in the research at any time without penalty. I understand that researchers will use my personal information to get information about me from other sources, as described above.”

Print Name of Study Participant

If you agree to let Researchers use your information, sign above date

If You Do Not Agree to Let Researchers Use Your Information, Sign Above Date

Parent or Guardian for HPOG applicants under the age of 18, your parent or legal guardian also must sign below:

Print Name of Parent/Guardian

If you agree to let researchers use your Child’s information, sign above date

If You Do Not Agree to Let Researchers Use Your Child’s Information, Sign Above Date

Attachment B: Informed Consent Forms  ▌pg. 1