Attachment A. Study consent form for HMRF participants

OMB Control No.: 0970-0531

Expiration Date: 09/30/2025

IRB Approved on: 2/6/2025

Valid until: 2/5/2026

Strategies To Respond to Intimate Violence Effectively (STRIVE) Project

Consent Form – Program Participant Survey

What is this study about?

Child Trends, a research organization, and Futures Without Violence, a non-profit health and social justice organization, are working with [PROGRAM NAME] on a study to learn if a new approach called CUES (confidentiality, universal education + empowerment, support) helps prevent and address domestic violence. CUES is designed to guide a one-on-one conversation and share helpful information and resources related to healthy relationships and domestic violence. This study is happening in four Healthy Marriage and Responsible Fatherhood (HMRF) programs across the country. The STRIVE study is funded by the Office of Family Assistance (OFA) and overseen by the Office of Planning, Research, and Evaluation (OPRE), both offices within the Administration for Children and Families (ACF) that is part of the United States Department of Health and Human Services (HHS).

What happens if I join?

If you join the study, you will complete two short surveys – one today and one in about a month. The surveys will ask some basic information about you and your knowledge and feelings around healthy and unhealthy relationships and your experiences in intimate relationships. The surveys will take about 10 minutes to complete, and you will receive a $10 token of appreciation for each survey.

Do I have to join?

You do not have to join the study. If you do join but change your mind later, you can stop participating at any time. Whether or not you participate in this study will not affect your ability to get services from [PROGRAM NAME]. When you are completing the surveys, you can skip any questions you don’t want to answer.

Will I benefit from being in this study?

You may learn new information about relationships. And others will benefit because we will learn if the CUES approach is helpful for people participating in HMRF programs.

Are there any risks?

There are two main risks:

• Feeling uncomfortable. Some questions may be uncomfortable for you to answer. You can skip any question you don’t want to answer.

• Loss of privacy. There is a small risk to your privacy. To help protect your privacy, we will not use your name when we write about the study, we will keep your name separate from your survey answers, and only members of the study team will be able to see your contact information.

What will you do with my information?

We will keep your information private to the extent allowed by law.

Your information will be collected using secure, online data collection software and will be saved directly onto a secure drive, only accessible to study team members. Once we have finished collecting and analyzing surveys, we will permanently delete all of your personally identifiable information and data.

When we write about the study, we will summarize what we have learned without using your name. Your information will not be used for future research.

Have questions?

If you have any comments or concerns about the study, you can call (240) 223-9291 to reach Sam Ciaravino, Study Director. If you want to know your rights as someone in the study, you can call or email the Child Trends’ Institutional Review Board (the group that approved this study) at: (855) 288-3506 or irbparticipant@childtrends.org.

The Paperwork Reduction Act Statement: The described collection of information is voluntary and will be used to better understand approaches to preventing and addressing intimated partner violence in HMRF programs. Public reporting burden for the described collection is estimated to average 28 minutes, including 8 minutes to review consent information and provide contact information, and 10 minutes to complete each survey. 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 the described collection is 0970-0531 and it expires on 09/30/2025.

Do you agree to join the study?

• Yes

• No

Signature:_______________________________