Appendix I - Adult Informed Consent Form

OMB Control # 0970 – XXXX

Expiration Date: XX/XX/XXXX

APPENDIX I

Childhood and Family Experiences Study

Informed Consent Form for Adults

You and your family are invited to take part in the Childhood and Family Experiences Study. This form explains what it means to be a part of this research project. The study seeks to learn what you think about your family’s income and household finances. This includes what your think about public benefits, if you receive them. Also, the study tries to understand how you talk about these things with your children. This study is being funded by the U.S. Department of Health and Human Services. MDRC, a nonprofit organization, is conducting the study. To help explain findings, MDRC may share information from this study with other researchers. MDRC will never share information with other researchers that includes your name or any other information that can identify you.

During this interview, we will ask you questions about:

• Your income and household finances,

• How you speak with your children about finances, and

• Any experiences you have had receiving public benefits.
  
  

Your opinions and ideas will help researchers and policymakers. We will better understand how families think about these matters. The interview takes about 1 hour and a half. At the end of the interview you will receive a $40 gift card. We will also interview your child or children and ask similar questions to the ones that we asked you. The interview with your child or children will last 30 minutes to 1 hour depending on their age. We are asking your consent to interview your child or children. If you consent, we will also be asking your child or children if they want to be interviewed. You will be able to see your child while he/she is being interviewed. After the interview is over, each child who is interviewed will receive a gift or a gift card to show our appreciation. Children between the ages of 7 and 11 will pick a gift from a bin containing books, colored pencils, and notebooks; children between the ages of 12 and 17 will receive a $25 gift card.

The interview is voluntary. If you decide not to participate, it will not affect any benefits or services you receive now or may receive in the future. It is possible that some questions may be stressful or upsetting. You can to skip any question or stop the interview if you or your children are upset by the questions asked. If you stop the interview, you will still receive the gift card.

Any information that could identify you will be protected. The researchers will not share your name with anyone. They won’t share any other information that could help to identify you with others. For example they wouldn’t share your date of birth or address. The information will be protected with a password. Only the research team will have access to this information. They will only use that information when they need to use it. The study has a Certificate of Confidentiality from the U.S. government. This certificate says that we do not have to identify you, even under a court order or subpoena. However, please keep in mind: we will keep your information private to the extent permitted by law. For example, if you or your child tells us that you intend to harm yourself or someone else we will have to tell the local authorities. Also, if your child tells us that he or she is being abused or neglected we will have to report that to the local authorities.

We may use what you say during the interview in our reports. But we won’t include your name or information that may identify you. Notes prepared from the interview will not include any information that would identify you, such as your name or where you live. The interviewers’ notes are for the research team’s use only. The notes will be stored securely. When the study is complete the notes will be destroyed.

Consent to Participate and Use the Information Collected

• I have read this form and have had a chance to ask questions and get answers about the study.

• I agree to be interviewed for the Childhood and Family Experiences study. I agree for my child named below to be interviewed as well.

• I understand that even if I give consent for my child to participate, he or she does not have to do the interview. My child will also have a chance to agree to participate in the study.

• I know that my participation and that of my child is voluntary.

• I know that information that could identify me and my child will be protected. It will only be seen by the researchers when they need it.

• I know that we can refuse to answer any questions. Also, we can end the interview at any time.

(Note: If you have more than one child taking part in the interview you will sign another form for them)

Name of Study Participant (Parent/legal guardian) (PLEASE PRINT)

Name of Child Interviewed (PLEASE PRINT)

Signature of Study Participant (Parent/legal guardian) Date

Signature of Interviewer Date

If you have any questions about the interview, please contact Sam Wulfsohn at MDRC via e-mail at Samantha.wulfsohn@mdrc.org or by phone at (212) 340-8860.

AUDIO ADDENDUM TO CONSENT FORM

You have agreed to participate in the Childhood and Family Experiences Study conducted by MDRC. We are asking for your permission to audio record the interview with you and your child/children. However, you can be a part of the study even if you do not want to be recorded.

The recording will help the research team check that their interview notes are accurate. The recording will not include your name or any other personal information. We will keep the names of people or places protected if you share those in the interview. Only the research team will have access to that information.

The audio recordings will be stored securely. They will be kept on a secure computer file and locked inside a file cabinet in a locked office. They will be separate from information that could be used to identify you, like your name or where you live. The audio recordings will be destroyed when the study is complete. The study will be completed in 2019, when the final report will be released.

Your signature on this form grants MDRC permission to audio record you and your child/children during your interview for the Childhood and Family Experiences Study. Consent to Be Audio-Recorded

• I have read this form and have had a chance to ask questions and get answers about the study.

• I agree to be audio recorded for the Childhood and Family Experiences study. I agree for my child named below to be audio recorded as well.

• I understand that even if I give consent for my child to participate, he or she does not have to do the interview. My child will also have a chance to agree to participate in the study.

• I understand that even if I give consent for my child to be audio recorded, this may not happen. My child will also have a chance to agree to be audio recorded in the study.

• I know that me and my child/children being audio recorded is voluntary.

• I know if you record information that could identify me or my child it will be protected. Only the research team will have access to that information.

• I know that we can ask the audio recording to be stopped at any time.

Name of Study Participant (parent/legal guardian) (PLEASE PRINT)

Name(s) of Children Interviewed (PLEASE PRINT)

Signature of Study Participant (Parent/legal guardian) Date

Signature of Interviewer Date

If you have any questions about the interview, please contact Sam Wulfsohn at MDRC via e-mail at Samantha.wulfsohn@mdrc.org or by phone at (212) 340-8860.

______________________________________________________________________________

This collection of information is voluntary and will be used to understanding the families’ experiences with money. Public reporting burden for this collection of information is estimated to average 90 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. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Sam Wulfsohn at MDRC via e-mail at Samantha.wulfsohn@mdrc.org.