2016 18-Month Survey Interviews - Parent

locating letter: alternate version for withdrawn cases

P.O. Box 2393

Princeton, NJ 08543-2393

Telephone (609) 799-3535

Fax (609) 799-0005

www.mathematica-mpr.com

[CONSENTING PARENT ADDRESS]

[CONSENTING PARENT CITY, STATE ZIP]

[FILL DATE (MM/DD/YYYY)]

Dear [CONSENTING PARENT / GUARDIAN NAME]:

Thank you for enrolling in the [PROMISE PROGRAM NAME] program in [FILL MONTH AND YEAR OF RA]. We understand that you enrolled in the [PROMISE PROGRAM NAME] program, but may not be receiving program services. The Social Security Administration has contracted with Mathematica Policy Research to evaluate this important program. Even if you are not receiving services from this program, we would like to include you in the evaluation. The evaluation will produce evidence on which services are most helpful for youth and their families.

When you enrolled, [PROMISE PROGRAM NAME] explained that Mathematica would reach out to you about completing interviews. The first one is in [FILL MONTH AND YEAR OF RA + 19 MONTHS]. Questions will be about your education, employment, health, well-being, and services that you may have received. When you and [YOUTH] complete the first interview, we will send each of you a $30 Walmart or Target gift card as a token of our appreciation.

If you have moved or have obtained a new telephone number since you

enrolled in [PROMISE PROGRAM NAME], please call us toll-free at

844-306-5011 to provide us with your updated contact information.

Participation in the evaluation is voluntary. You can decide to take part in the interviews or not. If you do not want to participate in the evaluation, please sign the statement below and return this page in the enclosed envelope.

Thank you again for enrolling in [PROMISE PROGRAM NAME].We hope that you will participate in the evaluation and we look forward to hearing from you soon if you have new contact information.

Sincerely,

Karen A. CyBulski – Survey Director for the [PROMISE PROGRAM NAME] Evaluation

***************************************************************************************

I do not want to participate in the [PROMISE PROGRAM NAME] evaluation. _________________________

(signature)

[STUDY ID]

Privacy Act Statement

Section 1110 of the Social Security Act, as amended, authorizes us to request this information. We will use this information to evaluate the impact of services provided to you (the minor participant or household member) during your participation in the Promoting Readiness of Minors in SSI (PROMISE) project. Providing us this information is voluntary. Failing to provide us with all or part of the information will not affect the SSI benefits that you, your child, or other household members receive now or in the future. We may use the information for the administration of our programs, including sharing information:

1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and the Department of Veterans Affairs); and, 2. To facilitate audit, investigative, or statistical research activities necessary to assure the integrity and improvement of our programs (e.g., to the Bureau of Census and to private entities under contract with us).

A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records Notice entitled, Supplemental Security Income Studies, Surveys, Records and Extracts (Statistics), 60-0203. Additional information about this and other system of records notices and our programs are available from our Internet website at www.socialsecurity.gov or at your local Social Security office.

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 0960-0799. The time required to complete this information collection is estimated to average 35 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.