Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
Evaluation of the ACL Title VI Programs
Title VI Program Staff Interview – 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 you are a staff person with an elders program in your community. We want to learn more about what these programs are doing for their communities and where they could use more help. The interview will last 1 hour.
Here are some things we want you to know about the interview before agreeing and consenting to participate:
Risk & Benefits
Participating in this interview is unlikely to cause any problems for you in any way. You can choose not to answer any question for any reason. You can end the interview at any time. 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.
Privacy
We will be taking notes during the interview about what is said, but your name and answers will be kept private to the extent permitted by law. To help with our notes, we also will audio record the interview. We will keep the notes and audio record 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 and will not contain any information about you or your community. While not the focus of our questions, if you tell us about child or elder abuse or neglect, we have to report to the appropriate authority per tribal and state legal codes.
Rights Regarding Decision to Participate
Participation in the interview 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 end the interview at any time, for any reason.
Contact Information
If you have any concerns about your participation in this interview 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
Before we begin the interview, I would like to get verbal consent to proceed. If you agree to take part in the interview, you are confirming that (1) this form 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 form will be provided to you.
Do you agree to participate in this interview?
Yes Thank you. I am confirming you are willing to answer questions during this interview and will note your verbal consent. We also would like to record the discussion to make sure we don’t miss anything.
No Thank participant for their time.
Do I have your permission to turn on the audio recorder?
Yes Thank you. Turn on recorder.
No Thank you. I will refrain from recording the interview.
Do you have any questions for me before we begin?
Pause for participant response. Answer any questions the respondent has. Proceed to conducting the interview using the Moderator Guide.
Evaluation of the ACL Title VI Programs
Title VI Program Staff Interview – Informed Consent Form (Copy for Participant)
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 you are a staff person with an elders program in your community. We want to learn more about what these programs are doing for their communities and where they could use more help. The interview will last 1 hour.
Here are some things we want you to know about the interview before agreeing and consenting to participate:
Risk & Benefits
Participating in this interview is unlikely to cause any problems for you in any way. You can choose not to answer any question for any reason. You can end the interview at any time. 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.
Privacy
We will be taking notes during the interview about what is said, but your name and answers will be kept private to the extent permitted by law. To help with our notes, we also will audio record the interview. We will keep the notes and audio 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 and will not contain any information about you or your community. While not the focus of our questions, if you tell us about child or elder abuse or neglect, we have to report to the appropriate authority per tribal and state legal codes.
Rights Regarding Decision to Participate
Participation in the interview 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 end the interview at any time, for any reason.
Contact Information
If you have any concerns about your participation in this interview 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.
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].
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Clarke, Gretchen |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |