Title VI Evaluation Follow-up Consent and Guide

Form Approved
OMB No.:
Expiration Date:

Evaluation of the ACL Title VI Programs
Title VI Program Staff Evaluation Follow-up Interview – Informed Consent Form
OMB Control: 0985-0059 Expiration Date: xx/xx/202x

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. We will roll all of the ideas into a report
which talks about the benefits and the best way to run elder programs.
Description of Participation
You have been asked to participate because you are a program director of a Title VI program which
participated in the Evaluation of the ACL Title VI Programs. We want to learn more about how your program is
now using evaluation and where you could use more help. The interview will last 45 minutes.
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
supports for Title VI programs.
Privacy
We will be taking notes during the interview about what is said, but your name and answers will be kept
secure 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.
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.

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 _________. 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 Office of Performance and Evaluation, Center for Policy and Evaluation, 330 C Street, SW, Rm 1229A,
Washington DC, 20201.

Form Approved
OMB No.:
Expiration Date:

Evaluation of the ACL Title VI Programs
Title VI Program Staff Evaluation Follow-up Interview – Informed Consent Form
OMB Control: 0985-0059 Expiration Date: xx/xx/202x

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. You may also contact ICF’s IRB at IRB@icf.com if you have any questions regarding your rights in
this discussion.
Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number (OMB 0985-0059). Public reporting
burden for this collection of information averages an estimate of 45 minutes per response, including time for
gathering, maintaining, and reviewing the data needed to complete the collection of information. The
obligation to respond to this collection is voluntary.

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 _________. 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 Office of Performance and Evaluation, Center for Policy and Evaluation, 330 C Street, SW, Rm 1229A,
Washington DC, 20201.

Form Approved
OMB No.:
Expiration Date:

Evaluation of the ACL Title VI Programs – Title VI Program Staff Evaluation
Follow-up Interview
Introduction and Informed Consent Statement
Thank you for giving us this chance to discuss your Title VI Program. This discussion should take no more
than 45 minutes of your time. We will do our best to stay on track.
As you may remember, I work for ICF and we are helping the Administration on Aging/ACL conduct an
evaluation of the Title VI Programs. You have been asked to participate because you are a program
director of a Title VI program which participated in the Evaluation of the ACL Title VI Programs. We want
to learn more about how your program is now using evaluation and where you could use more help.
There are no right or wrong answers. You are the expert on your Title VI program, and your opinions and
thoughts are really important to us. You can choose not to answer any question for any reason. 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.
Your interview responses will be kept secure to the extent permitted by law. To help with our notes, we
also will audio tape the interview. We will keep the notes and tape 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.
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.
Do you have any questions before we get started?
Do you consent to participate in the interview?  Yes
Do you agree to be audiotaped?

 Yes

 No

 No

[Moderator begins recording.]

First, I want to ask you a couple of questions about your participation in the Evaluation of the ACL
Title VI Programs (Title VI Evaluation).
1. What was your experience participating in the Title VI Evaluation?
a. What stood out for you?
b. What are 3 things you learned or took away from your participation in the Title VI
Evaluation?
2. How did your understanding of evaluation change as a result of participating in the Title VI
Evaluation? How would you describe evaluation?
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 _________. 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 Office of Performance and Evaluation, Center for Policy and Evaluation, 330 C Street, SW, Rm 1229A,
Washington DC, 20201.

Form Approved
OMB No.:
Expiration Date:

Now, I’m going to ask you to think about your Title VI program.
3. What type of program information or data do you currently collect as part of your Title VI
program?
a. Has this changed in the last three years? If so, how/why?
4. How do you currently collect/track this program data?
a. Probe: sign-in sheets, activity logs, satisfaction surveys, intake forms
5. What tools or resources have helped you collect/track program data?
6. What factors make collecting program data challenging?
7. How do you use the program data you collect?
a. Engaging stakeholders (e.g., reports to council/tribe, funders)?
i. If using data for engaging stakeholders  please share an example of what that
looked like (what data, what format for sharing - infographic, monthly report,
etc)
b. Program planning/improvement?
i. If using data for program improvement  please share an example of what you
did (Probe: what data, what it showed, what changes they made as a result)
8. How do you currently assess/evaluate the implementation of your Title VI/Elders’ program?
a. Meeting elders’ needs?
b. Meeting caregivers’ needs?
c. Assessing gaps in services?
9. If not currently assessing/evaluating implementation of your Title VI/Elders’ program, do you
have plans to do so? Tell me about that.
10. What makes assessing/evaluating your Title VI/Elders Program:
a. Successful?
b. Challenging?
11. Has your process for assessing/evaluating your program changed in the last three years? If so,
how/why?
12. How do you share program successes with stakeholders?
a. Has this changed in the last three years? If so, how/why?
13. What tools or resources do you think would help you better understand how well your program
is meeting elder and caregiver needs?
14. Anything else you would like to share?
Thank you for taking the time to speak with me today!
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 _________. 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 Office of Performance and Evaluation, Center for Policy and Evaluation, 330 C Street, SW, Rm 1229A,
Washington DC, 20201.