Appendix 1_TIES_Consent Materials for Fathers_30dayFRN_Clean

OMB #XXXX-XXX

Expiration Date: XX/XX/XXXX

Consent Materials for Fathers

Agreement to Participate

Fatherhood TIES

You are invited to take part in Fatherhood TIES (which is short for the Testing Identified Elements for Success in Fatherhood Programs project). A nonprofit organization called MDRC is running the study with MEF Associates, Mathematica Policy Research, and Abt Associates. This form describes Fatherhood TIES and explains what it means for you to be a part of it. If you agree to participate, we will ask you to sign this form and give you a copy. Your participation is voluntary.

What is Fatherhood TIES?

Fatherhood TIES is an important project that aims to find out which parts of fatherhood programs are most effective at improving the lives of participating fathers and their children and co-parents. You will have the chance to receive innovative services that may help you achieve your goals in your work and family life. This project will help your fatherhood program learn if it is meeting the needs of people like you and improve services for fathers in the future. You are one of thousands of fathers from around the country who we are inviting to share their story and be part of this project.

What does it mean to be a part of this study?

If you agree to be in Fatherhood TIES by signing this form, we will ask you to do the following:

• Take a survey when you enroll in your fatherhood program. This is in addition to the other surveys your program asks you to take to enroll in the program.

• It will take about 20 minutes to complete.

• We will ask questions about you and your family. We will ask about your relationship with your children and co-parent(s), any history with the criminal justice system and, and other topics. You may skip any of the questions you do not wish to answer.

• You will receive $25 for completing the survey.

• Receive text messages from us.

• We will ask for a phone number to stay in touch with you. We may send you text messages.

• The message frequency will depend on your activity. You may text “STOP” at any point to opt-out of text messaging. Message and data rates may apply.

• Receive a welcome packet in about a month.

• It will include Frequently Asked Questions, explain privacy, and talk about how you can access the participant portal to update your contact information.

• The welcome packet will include $5 as a token of appreciation for being in the project.

• Take a second survey in the future, about nine months from today.

• We will ask about your experience in the program, your relationship with your children and co-parent(s), and other topics.

• You may skip any of the questions you do not wish to answer.

• Allow us to obtain information about you and your participation in fatherhood services.

• This will include information related to how often you attend your fatherhood program and which services you participate in. We will also access background demographic information about you, provided at the time of your program enrollment.

• Allow us to obtain information from state and federal agencies about the services you receive.

All information about you will be stored with a special code, not your name. This information will not identify you. We will collect this information for up to 10 years from today.

• This may include information about topics like your earnings, child support that you owe and pay, education, or use of other government services.

• To get this information, we will use your Social Security number. Your Social Security number also helps us locate you when we want to talk to you in the future. Supplying your Social Security number is voluntary.

• Allow us to contact you at some time in the future with opportunities to share your story.

• The project team may reach out to you through the program staff, or directly by phone, email, or text to ask you to share your experiences with the fatherhood program. You may be asked to share your thoughts through journaling, photography, focus groups, or interviews.

• These activities are voluntary. If we do talk to you, you may refuse to answer any questions we ask.

How will my information be protected?

Information about you will be stored with a special code, not your name. No reports will describe you in a way that would allow you to be identified. We need to deliver the project data to the federal government at the end of the project, but the data file will not contain information that could be used to identify you. This will not include audio files, photography, or notes from focus groups or interviews.

The project team will follow strict rules to keep your information private. The project team is trained to protect privacy. The team signs a privacy pledge. Right now, we plan to collect information about you for up to one year. The project might be extended, however. If that happens, we might continue to collect your information or we might share your information with other researchers. They might continue to collect information about you and your family. All information about you will be stored with a special code, not your name. They would also keep your information private. If the project is extended, you will not be asked to give permission for this use. You are agreeing now to sharing this information for any other purpose in the future.

The project 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. The government may see your information if it audits the project, but it would keep your information private. Please keep in mind: if keeping your answers private would put you or someone else in serious danger, we will have to tell the appropriate agencies to protect you or that other person.

Will my information be used in the future for other studies?

Yes. The study team will securely maintain the data from this study. At the conclusion of the study, our study team will archive the data as a restricted use file with a trusted data repository. A restricted use file means that only qualified researchers will be able to access the data for use in future research projects, without collecting additional consent. This will not include audio files, photography, or notes from focus groups or interviews. The data we share will not include your name or other information that could directly identify you. If you join this study, you are agreeing now to share the information that you provide for other research purposes in the future. 

What are the benefits and risks of participating in the project?

Taking part in the project may help improve services for fathers.

There are some risks to participating in the project. Any data storage has a small risk of your information being seen outside of the project team in the unlikely event of a data breach, such as a breach in computer security. However, we follow strict rules to protect your data privacy. No reports will include your name or identifying information.

We will keep your information private unless there is concern that you or someone else may be harmed. For example, we would tell someone if we see evidence of child abuse or neglect.

Being part of the project is your choice.

{for parent coaching or financial coaching sites} Taking part in the project is your choice. If you decide not to be in Fatherhood TIES, there is no penalty. Your decision will not affect the fatherhood services you receive.

{for systems navigation sites only}: Taking part in the project is your choice. If you decide not to be in Fatherhood TIES, we will not be able to decide whether you're eligible for project-related services that will allow some fathers to access extra support with child support and legal systems. You will only be able to receive the program’s business as usual services.

If you decide to be in Fatherhood TIES, you can change your mind at any time by contacting MDRC at the e-mail or phone number below. If you choose to opt out, the project team may still use information that was collected about you while you were in Fatherhood TIES. You will not lose any services to which you would otherwise be entitled.

Who can I call with questions?

MDRC and Fatherhood TIES can be reached at FatherhoodTIES@mdrc.org or at the Fatherhood TIES hotline (855) 907-6696.

Consent statement:

Will appear on nFORM screen

By signing my name below, I attest that this father agrees with the following statement: “The research procedures, risks, and benefits have been explained to me. I know I am free to ask any questions. I understand taking part in the project is my choice. I understand that taking part in the project may affect the services I am eligible for from this program. I understand that the project will collect information about me. I know I can stop being a part of the project at any time. I know I can refuse to answer any questions during an interview. I understand my information will be kept private, unless there is a concern that I or someone else may be harmed. I agree to provide contact information so I can be reached in the future.”

Does this father consent to participate in this study? Yes No [Choose one]

My signature affirms that this father verbally consented to participate in the Fatherhood TIES study.

____________________________________________________________________________________

Your Name (Print)

Consent not granted

PRIVACY STATEMENT: The consent is covered by the Privacy Act. This means that your participation is voluntary, so you can decline to participate. If you decide to decline to participate, you may lose the chance to receive innovative services that may help you achieve your goals in your work and family life. The purpose of this study is to find out which parts of fatherhood programs are the most effective at improving the lives of participating fathers and their children and co-parents. The information you provide may be shared with state and federal agencies and researchers involved in similar work. The legal authority for this project is [insert funding stream for the project]. If you would like more information about this project, please see Systems of Records Notice (SORN) 09-80-0361, OPRE Research and Evaluation Project Records.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of the described information collection is to gather preliminary information about the fatherhood field and explore with fatherhood programs the research questions that are of interest and the design options that are feasible. This is a voluntary collection of information. The answers you give will be kept private. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # for the described information collection is XXXX-XXXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Dina Israel; Dina.Israel@mdrc.org, and Michelle Manno; Michelle.Manno@mdrc.org; Attn: OMB-PRA (XXXX-XXXX).