Appendix G Previously Approved Consent Forms for Participant Surveys

Supporting
Statement for OMB
Clearance Request
Appendix L: Consent
Forms for Participant
Surveys
National Implementation
Evaluation of the Health
Profession Opportunity
Grants (HPOG) to Serve
TANF Recipients and
Other Low-Income
Individuals and HPOG
Impact Study
0970-0394

April 24, 2013

Submitted by:
Office of Planning,
Research & Evaluation
Administration for Children & Families
U.S. Department of Health
and Human Services

Federal Project Officers:
Molly Irwin and Mary Mueggenborg

Appendix L

OMB # 0970-0394
Expiration Date xx/xx/xxxx

Appendix L: Consent Forms for Participant Surveys
HPOG-NIE Informed Consent

OMB Control No. 0970-0394
Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 08592-100/110-00

AGREEMENT TO TAKE PART IN THE
HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM AND STUDY
This program is part of a new national project to train people for health care jobs. The program is
funded by the U.S. Department of Health and Human Services in Washington, DC. That agency
is also funding research to study how well our program works in helping people get training and
jobs. Over the next several years, researchers will be using information about people in the
program to do their studies. Researchers from Abt Associates and the Urban Institute are doing
the current study. Other researchers may engage in future studies. You are invited to take part in
this important research.
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. They want: 1) information
about the training and services you get in the program; (2) information about you and your
family, your education, and work history; and (3) personal data such as your Social Security
number so they can get information from government sources about your future employment,
earnings, education, and public benefits like welfare.
Abt Associates, The Urban Institute and future 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. 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 find and keep a job in health
care. 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.
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.
By participating in the study, 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 health care 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
1

OMB Control No. 0970-0394
Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 08592-100/110-00

to answer some questions about your experiences. While we encourage you to answer their
questions, you may refuse to answer them.
This agreement is effective from the date you sign it (shown below) until the end of the research
studies or when you choose to withdraw permission.
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 either Alan Werner (Abt Associates) at 617-492-7100, EXT 2832 (toll
call).
Statement
“I have read this form and agree/do not agree to allow information about me to be used in the
national Health Profession Opportunity Grant Program research studies. I know that my
participation in the research study is voluntary, that Abt Associates, the Urban Institute and any
future 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 Abt Associates, the Urban Institute
and other 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

Institutional Review Board
Study Approval Date: 9/30/11
Study Expiration Date: 9/29/12
IRB Study#: 0572

2

Appendix L

OMB # 0970-0394
Expiration Date xx/xx/xxxx

HPOG-Impact Informed Consent for Sites Implementing Enhancements

(Office Use Only—HPOG ID Number: _________________)

OMB Control No. 0970-0394
OMB approval expires 10/31/2014
Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 0189

AGREEMENT TO TAKE PART IN THE
HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM (HPOG)
RESEARCH STUDIES
The Health Profession Opportunity Grant (HPOG) program is a new job training program that is
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. HHS has funded Abt
Associates and The Urban Institute to conduct two related research studies of HPOG to learn how
well the program works. This form (1) describes these two HPOG studies and (2) requests your
participation in these studies. We need to tell you about these two studies and what it means to
be part of them. Only individuals who agree to participate in the studies will be able to enroll in
the HPOG program.
Research Overview
The two studies of HPOG being funded by HHS are described below:
(1) The HPOG National Implementation Study. This evaluation will describe and evaluate how
HPOG operates. As part of this evaluation, the study team will collect data about all HPOG
grantees and all individuals who enroll in HPOG.
(2) The Impact Study of the Health Professions Opportunity Grant (HPOG-Impact). Over the next
12 – 16 months, the [name of HPOG program] will also be in the HPOG-Impact study. The
study will assess if and how HPOG makes a difference in people’s lives. The study will also
determine if HPOG helps people complete training and get healthcare jobs
The studies also will help the government learn how to improve the HPOG program, and similar
programs, in the future. As part of the impact study, the study team will collect data from people
enrolled in the HPOG program. The study team will also collect information from people enrolled
in the “enhanced” HPOG program (slightly different from the regular HPOG program). Finally,
the study team will collect information from a control group of individuals who are not enrolled in
HPOG. We expect a total of 10,500 people at up to 20 HPOG grantees to participate in HPOGImpact.

▌pg. 1

(Office Use Only—HPOG ID Number: _________________)
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 one of two programs operated by [name of HPOG program].
Alternatively, you may be assigned to the non-HPOG group. If you are assigned to the non-HPOG
group, you will not be able to enroll in [name of HPOG program], but can enroll in any other
service or program for which you are eligible. 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. However, you will be able to enroll in any other service or program for which you are
eligible.
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 about the training and services you get in the program. If you are not
in the HPOG program, researchers will want information about training and
services you get outside the program;
2) Information about you, your family, your education, and your work history;
3) Personal data (e.g., Social Security Number) so researchers can get information
about your future employment, earnings, education, and public benefits like
welfare; and
4) If you have children, researchers would like to request information about their
birthdates and names. Researchers may 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 a study in the future.
You may refuse to answer any specific question at any time.
By participating in these studies, you will help the federal government and programs around the
country learn about the best way to provide training and help people get a health care job. You
will be asked for information at certain times during your time in the program and after you
leave the program. While we encourage you to answer their questions, you may refuse to answer
them.
Abt Associates, The Urban Institute and future 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. 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 find and keep a job in
healthcare. 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.
This agreement is effective from the date you sign it (shown below) until the end of the research
studies, 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 your case
manager or person who enrolled you in the program.
▌pg. 2

(Office Use Only—HPOG ID 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 Alan Werner (Abt Associates) at toll-free 855-551-0919.
Statement
“I have read this form and agree to participate in the Health Profession Opportunity Grant
Program research studies. I know that if I do not consent to be in the research I will not be able
to enroll in the [name of HPOG program] program. Abt Associates, The Urban Institute and any
future researchers will use data security procedures to keep all of the study information private as
described above. My name will never appear in any public report. I know that I can refuse to
answer any questions researchers might ask me. I understand that Abt Associates, The Urban
Institute and other researchers may contact me in the future and will use my personal information
to get information about me from other sources, as described above.”

PRINT YOUR NAME ABOVE

IF YOU AGREE, SIGN ABOVE

DATE
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number. The valid OMB control number for this information
collection is 0970-0394. The time required to complete this information collection is estimated to average 15 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. This information collection is voluntary. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

▌pg. 3

Appendix L

OMB # 0970-0394
Expiration Date xx/xx/xxxx

HPOG-Impact Informed Consent for Sites Not Implementing Enhancements

(Office Use Only—HPOG ID Number: _________________)

OMB Control No. 0970-0394
OMB approval expires 10/31/2014
Abt Associates IRB Approval No. 0572
Urban Institute IRB Approval No. 0189

AGREEMENT TO TAKE PART IN THE
HEALTH PROFESSION OPPORTUNITY GRANT PROGRAM (HPOG)
RESEARCH STUDIES
The Health Profession Opportunity Grant (HPOG) program is a new job training program that is
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. HHS has funded Abt
Associates and The Urban Institute to conduct two related research studies of HPOG to learn how
well the program works. This form (1) describes these two HPOG studies and (2) requests your
participation in these studies. We need to tell you about these two studies and what it means to
be part of them. Only individuals who agree to participate in the studies will be able to enroll in
the HPOG program.
Research Overview
The two studies of HPOG being funded by HHS are described below:
(1) The HPOG National Implementation Study. This evaluation will describe and evaluate how
HPOG operates. As part of this evaluation, the study team will collect data about all HPOG
grantees and all individuals who enroll in HPOG.
(2) The Impact Study of the Health Professions Opportunity Grant (HPOG-Impact). Over the next
12 – 16 months, the [name of HPOG program] will also be in the HPOG-Impact study. The
study will assess if and how HPOG makes a difference in people’s lives. The study will also
determine if HPOG helps people complete training and get healthcare jobs
The studies also will help the government learn how to improve the HPOG program, and similar
programs, in the future. As part of the impact study, the study team will collect data from people
enrolled in the HPOG program. Finally, the study team will collect information from a control
group of individuals who are not enrolled in HPOG. We expect a total of 10,500 people at up to
20 HPOG grantees to participate in HPOG-Impact.

▌pg. 1

(Office Use Only—HPOG ID Number: _________________)
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]. Alternatively, you may not be
invited to participate in [name of HPOG program]. 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. 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.
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 about the training and services you get in the program. If you are not
in the HPOG program, researchers will want information about training and
services you get outside the program;
2) Information about you, your family, your education, and your work history;
3) Personal data (e.g., Social Security Number) so researchers can get information
about your future employment, earnings, education, and public benefits like
welfare; and
4) If you have children, researchers would like to request information about their
birthdates and names. Researchers may 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 a study in the future.
You may refuse to answer any specific question at any time.
By participating in these studies, you will help the federal government and programs around the
country learn about the best way to provide training and help people get a health care job. You
will be asked for information at certain times during your time in the program and after you
leave the program. While we encourage you to answer their questions, you may refuse to answer
them.
Abt Associates, The Urban Institute and future 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. 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 find and keep a job in
healthcare. 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.
This agreement is effective from the date you sign it (shown below) until the end of the research
studies, 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 your case
manager or person who enrolled you in the program.

▌pg. 2

(Office Use Only—HPOG ID 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 Alan Werner (Abt Associates) at toll-free 855-551-0919.
Statement
“I have read this form and agree to participate in the Health Profession Opportunity Grant
Program research studies. I know that if I do not consent to be in the research I will not be able
to enroll in the [name of HPOG program] program. Abt Associates, The Urban Institute and any
future researchers will use data security procedures to keep all of the study information private as
described above. My name will never appear in any public report. I know that I can refuse to
answer any questions researchers might ask me. I understand that Abt Associates, The Urban
Institute and other researchers may contact me in the future and will use my personal information
to get information about me from other sources, as described above.”

PRINT YOUR NAME ABOVE

IF YOU AGREE, SIGN ABOVE

DATE
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13), no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number. The valid OMB control number for this information
collection is 0970-0394. The time required to complete this information collection is estimated to average 15 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. This information collection is voluntary. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

▌pg. 3