Welfare Reform and Family Self-sufficiency

Informed Consent

We have asked you to participate as an author as part of a study examining how a change in federal policy known as welfare reform has affected people receiving service at ______________________ (agency name) and other similar agencies around the country. You have been selected because it is likely that you have been affected by welfare reform.

1. Participation in the study is completely voluntary.

You may leave at any time if you are not comfortable or do not wish to share your story.

2. Participation will not affect your benefits.

Your decision about participation will in no way affect any public assistance benefits you may have or the services you receive from this agency.

3. The session in which you share your story will last for approximately 30 to 60 minutes.

I will ask you several questions about your family’s and children’s well-being, who helps out with parenting and managing the household, housing and home life issues, your emotional well-being, and your experience with employment. You may write out your answers, or your responses to these questions will be recorded or may be written down by me.

4. The session in which you share your story is confidential.

No last names or identifying information about you will be used after you leave this room. Any papers with identifying information will be destroyed after the study has been completed. At the end of the session, I will ask you to sign your name and address on a separate list in exchange for compensation you will receive for your participation. I will also keep this list in a locked cabinet separate from the copy of your interview.

5. You will receive a copy of the study’s final report.

Your name will not appear in that report. We will publish your story on the Alliance web page, but no identifying information will appear with that story.

6. No risk in participation is anticipated.

We do not anticipate any risk to you for participating in the study. However, people have strong feelings about the issues we are discussing and we want to acknowledge that sharing them may arouse some discomfort.

7. You may contact me at _______________________ if you have questions.

(agency phone number)

Consent Form

Page 2

Please indicate below that you have read and understand this informed consent. I will collect the signed copy and you may keep the other copy in case you want to contact us at a later time.

I ______________________________ (participant name) state that I am 18 years of age or older and wish to participate in the interview component of the Welfare Reform study being conducted by the Alliance for Children and Families. I understand the purpose of the research and how the results will be used. I understand that I do not have to participate and may leave at any time. I know that participation will not affect my eligibility for public benefits. I know that I can contact the researcher if I have questions. I will be given a copy of this form. I consent to participation in the study.

________________________________

Signature of Participant

____________

Date