Attachment D - Self Sufficiency Matrix Instructions & Consent

Self-Sufficiency Matrix Instructions

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering data on your grant program to understand the design and effectiveness of the program and to inform technical assistance needs. Public reporting burden for this collection of information is estimated to average 90 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. 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 # is 0970-0628 and the expiration date is xx/xx/xxxx. If you have any comments on this collection of information, please contact juliana.melara@acf.hhs.gov.

Instructions:

The following matrix should be conducted with each client receiving case management services. We estimate that this matrix will take between 60 and 90 minutes to complete with each client.

This matrix is voluntary, and the caseworker should review the study information sheet about the data collection process with the client. Be sure to remind the client that the information will be used to improve overall programming, but the information shared with the federal research team will not be individually identifying (in other words, the information held by the federal research team will not allow the federal team or others to identify individuals in the study). The caseworker should inform the client that they will receive $25 token of appreciation for participating in the data collection. The caseworker should confirm that the client consents to sharing the information with the research team for the purposes of the evaluation, and that if they do not want to share their information, it will not affect their services in any way. Sharing information for the study is completely voluntary. The caseworker should also inform the client that they can feel free to skip any section of this matrix (i.e., the client could answer the section about childcare, but decline to answer the section about mental health).

The caseworker should inform the client that information shared may be used by the caseworker to improve the service provision to the grant recipient. The caseworker should tell the client if they are a mandated reporter (i.e., if the caseworker has a responsibility to report child abuse/neglect or to report risk of suicide/homicide). If the caseworker has a responsibility to share potentially illegal actions (such as drug use) with the relevant authorities, the caseworker should share this with the client before beginning the matrix.

The caseworker should sit down with the client and complete the matrix collaboratively, in a conversational style. For example, with the domain of employment, the caseworker could ask the client how they feel they are doing with regards to work. The caseworker can probe for more details (“Are you working full-time? Do you receive health insurance through your job?”) in order to select the matching score.

After completing the matrix with the client, the caseworker should provide the client with the token of appreciation.

AHSSD Individual Unique Identifier:___________________________

AHSSD Household Unique Identifier:____________________________

MM/YY for this administration of the matrix:__________________________

MM/YY when case management services began:_________________________

MM/YY when case management services ended (if applicable):_________________

# of case management sessions with client in past 6 months (if applicable): _______________

Use the checkbox below to confirm the client consented to providing deidentified self-sufficiency matrix data for the evaluation:

• Client consented to sharing deidentified self-sufficiency matrix data for the evaluation.