7 Tribal Caregiver Survey Consent Form

Form Approved

OMB No.: XXXX-XXXX

Expiration Date: XX/XX/2017

Evaluation of the ACL Title VI Programs

Title VI Tribal Caregiver Survey – Informed Consent Form

Purpose of the Study

The Administration for Community Living (ACL) has hired ICF to find out how well the elders’ programs in our country are serving their communities. ICF will be talking to program leaders, elders, and caregivers to learn how the services in their communities help to make their lives better. We will also be looking for ideas to share with programs all over the country. In order to do this, we will be talking with elders’ program staff, elders, and caregivers to ask their ideas and thoughts. We will roll all of the ideas into a report which talks about the benefits and the best way to run elders programs.

Description of Participation

You have been asked to participate because your tribal elders program told us you are a caregiver who received some services from them. The survey has 36 questions and will take about 25 minutes to finish.

Here are some things we want you to know about the survey before agreeing and consenting to participate:

Risks & Benefits: Participating in this survey is unlikely to cause any problems for you in any way. You can choose not to answer any question for any reason. You can stop the survey at any time or skip any questions you don’t want to answer. Your answers will not give you any benefits or change any benefits that you currently may be receiving. Your input will be used to help improve programs in tribal communities.

Compensation: If you agree to take part in this survey, you will receive [insert incentive].

Privacy: Your name and answers to these questions will be kept private to the extent permitted by law. We will keep the records in locked files, and only study staff will be allowed to see them. The information that we report will be grouped together with the results from all tribes, will not contain any information about you or the person you care for (your care receiver). Your name will not be released to anyone, included in the information, or used in any reports about this evaluation.

Rights Regarding Decision to Participate: Participation in the survey is completely voluntary. You can refuse to participate with no penalty or negative results. You do not have to answer questions that you do not want to answer. You may choose to stop the survey at any time, for any reason.

Contact information: If you have any concerns about your participation in this survey or have any questions about the evaluation, please contact the project manager, Gretchen Clarke, at gretchen.clarke@icf.com or (907) 747-7124, or contact the ACL Contract Officer Representative, Kristen Hudgins, at kristen.hudgins@acl.hhs.gov or (202) 795-7732.

Voluntary Consent: If you agree to take part in the survey, you are confirming that (1) you have read this form, or it has been read to you, (2) that you understand what it says, and (3) all of your questions have been answered. A copy of this from will be provided to you.

Do you agree to participate in this survey?

₁ Yes

₂ No

Public Burden Statement: 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. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time to review instructions. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to [title], [address, city, state, zip].