Appendices F - I

APPENDIX F
INFORMED CONSENT MATERIALS

Cuyahoga County Baseline and Follow-up Client Information Sheet and Signature Form
for Non-incarcerated Clients..............................................................................................F1
Cuyahoga County Prison/Jail Client Information Sheet and Signature Form....................F2
Clermont County Baseline and Follow-up Information Sheet and Signature Form for
Non-incarcerated Clients....................................................................................................F3
Clermont County Prison/Jail Client Information Sheet and Signature Form.....................F4
Informed Consent Addendum to Conduct Urine Toxicology Test....................................F5

FORM APPROVED

CUYAHOGA COUNTY, OHIO OMB No. 0930-0248
Expires 10/31/06

See burden statement for baseline questionnaire

Program Rehabilitation and Restitution (PRR) Project Consent Form
Baseline and Follow-up Client Information Sheet
for Non Incarcerated Clients
About This Study
You are being asked to participate in a study about the benefits to people when they
are offered the opportunity to have the stigma of a criminal record removed. In the State
of Ohio, first time non-violent felons who have not been convicted of: An offense that
carries a mandatory prison term, most sex offenses, traffic offenses including Driving
while under the influence of Alcohol and/or Drugs (DUI), Driving Under License
Suspension (DUS), any other offense of violence, crimes against a minor, or any first or
second degree felony may have their records sealed after three years post supervision and
at the discretion of a judge if they have not committed any additional offenses during that
time. This opportunity is open to all eligible first time non-violent felons regardless of
whether they participate in this study. However, if you do participate in the study, there
may be an opportunity to get more case management and treatment services that possibly
may help you to keep a clean record and achieve having your records sealed. Please ask
the person interviewing you to explain anything you don’t understand. To help you, we
will read through the information together.
Involvement in the Project
We need your help in conducting the study, but your involvement in this study is up
to you. Please understand that your participation is voluntary and you are free not to take
part in the study, now or later. You are free to withdraw from the study at any time. If
you choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled; your decision will not affect your receiving the treatment or
the services you would have received if you had not been asked to participate in the
study.
Description of the Project
This study is supported by the federal government, namely the Center for Substance
Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services
Administration (SAMHSA). The evaluation is under the direction of the Center for the
Integration of Research and Practice (CIRP) at the National Development and Research
Institutes, Inc. (NDRI). The reason for this study is to help people like you to get their
criminal records sealed and reduce the stigma of a criminal record. The research will
help us understand the types of programs that work best to help individuals rehabilitate
and return to the community, and the information you provide may lead to positive
changes in agencies that aim to rehabilitate offenders.
Your Role in the Study
As part of the study, you may receive additional treatment services beyond those
normally provided, such as additional case management, substance abuse treatment, and
other services. Participation in this study is voluntary, but we hope you will want to help
with this important study. If you decide to be in this study, you will be asked to
participate in four research interviews, which you will be compensated for with the
exception of any interviews conducted in prison. The clinical baseline interview will take
place in approximately 14 days from today and will be conducted with your case
1

CUYAHOGA COUNTY, OHIO

manager. The second, third, and fourth interviews, which are the research interviews will
be conducted 6 months from now, 12 months from now, and then 42 months from now to
see how you do in the future and will be administered by the Education Development
Center (EDC) as a representative of the research group and therefore all information
gathered during these interviews will be used for research purposes only and will not be
shared with any other agency outside the research group. Each interview will take one
hour-and-a-half to two hours. If you decide to volunteer, you will be asked questions
about yourself and what is happening in your life, including your health, substance use,
mental health, current and past housing, and use of the services to which you are referred.
In addition to the interviews, we will also collect some information about you from
TASC files, probation, parole or post release control, program providers, and state
agencies that collect information on the use of treatment programs and other services.
You are helping us by participating in the study. We will compensate you $20 for
your first interview, $25 for the second interview, $30 for the third interview, and $35 for
the fourth interview. Furthermore, at the time of the fourth interview you will also be
asked to provide a urine sample for research purposes. Your participation in the urine
drug test is voluntary and results will be kept confidential. You will be compensated an
additional $10 for providing a urine sample. Therefore, if you complete the fourth
interview and participate in the urine test, you will be compensated a total of $45. You
do not need to participate in the urine drug test in order to participate in this study. You
do not need to decide now whether you would like to volunteer for the urine test. At the
time of the fourth interview the researcher will review the terms with you again and have
you sign a separate consent form should you volunteer to participate in a urine drug test.
In addition to being interviewed, you may be asked to be in a focus group. You
do not have to be in the focus group to be in the study; however, if you decide to do it,
you will be compensated $35 for any focus group that you attend. We will also ask your
consent to audio-tape the focus group. No last names will be used in the focus group to
protect the identity of the participants. We will not be able to compensate you for any
focus groups that you participate in while incarcerated.
This project is designed to help you to increase the chances of sealing your
criminal records, but does not guarantee that your records will be sealed. There are many
reasons why your record may not become eligible for sealing. Some examples include a
record of past/prior incarcerations; an incomplete history of past arrests or incarceration
in the State of Ohio or other states, the judge reviews your record and feels that you have
not met the necessary criteria.
Potential Risks and How You Are Protected
The risks of the study are relatively small and the benefits are high. During the
course of the interviews, participants may become concerned about the consequences of
their past drug use or difficulties with maintaining abstinence and express a need for
help/services.
A. Distress
There is a possibility that some of the questions in the interviews may make you feel
uncomfortable. Some of the questions are about troubling events that you may have had
in your life. Some people feel upset when they have to recall troubling events in their
lives. If you feel uncomfortable, we can do any of the following: you can choose not to
answer certain questions; you can take a break and continue later; or, you can choose to
2

CUYAHOGA COUNTY, OHIO

stop the interview. Your case manager and other staff members will be available to make
sure you have someone to help or assist you.
B. Identity
The risk of your identity being revealed is minimal because we have taken great
efforts with your records to comply with confidentiality standards to protect your
identity. The information gathered about you, including your answers to the interview
questions, will be stored in secured files, and you will be identified only by code
numbers. The Principal Investigators, Dr. Harry Wexler and Dr. Gerald Melnick will
keep a logbook of names and code numbers in a locked file that only they and the Project
Director can open. The locked file will be kept at NDRI offices in New York City. Only
information about the whole group will be reported out, and it will not be possible to
identify any one person. Project staff is also carefully trained to maintain strict
confidentiality in order to protect your privacy.
Confidentiality
Because we have taken steps to protect your confidentiality, the risk of unauthorized
disclosure is minimal. To help keep information about you private and confidential, we
have applied for a Confidentiality Certificate from the Federal agency giving us money
for the study, the Department of Health and Human Services. This certificate means that
we cannot be forced to give information about you from the research interviews and
focus groups to others, even if a court has ordered us to do so using a subpoena.
However, if you say you have been harming or abusing a child or an elderly person, we
will be required to report that. If you tell us you are going to physically hurt yourself or
someone else, we will contact someone who can help. If you commit a crime on our
treatment premises or against a treatment service provider, we will report such incidences
to the proper authorities. There is also a possibility that the agency giving us money for
this study will want to do an audit, that is, check to see if we are using the grant money
the right way. If they do an audit, we have to let them see any files they need, including
files that contain your information although they may use this information only for the
purposes of the audit. Also, the Certificate does not prevent you or your family from
releasing information about yourself or your involvement in this research.
Also, you can give permission to let people know that you are in the study. If you
have any questions about the interview, please ask the person who is interviewing you.
You can also call the evaluators at National Development and Research Institutes, Inc. to
talk more about the session. If you have questions about the study or feel you have been
hurt by the study, you may call Harry K. Wexler, Ph.D. (212.845.4400), who is in charge
of the study. If you have questions about your rights as someone who is taking part in
this study, you can call Fred Streit, Executive Director/ CEO of NDRI (888.845.4695).
C.

Other Information about You
We will also ask you to give us the names and telephone numbers of people who can
help us get in touch with you for the purpose of your participating in the interviews or
focus groups. We will only contact these people if we can’t reach you at the phone
number and address you have given us for yourself and they will be told only that we are
attempting to locate you because you are part of the EDC study.
If there are any questions you find objectionable, we would prefer that you do not
answer them rather than give false answers.
Please sign the form stating that you understand the purpose of this interview. This
agreement will be valid for the duration of the study.
3

CUYAHOGA COUNTY, OHIO

Program Rehabilitation and Restitution Project (PRR)
Informed Consent Client Signature Form

I, ________________________________________________, hereby give my consent
and understand the Client Information Sheet and the informed consent form including the
description of the study and its possible benefits, my role in the study, the possible risks,
and the steps taken to protect me. I understand the following:
My participation is voluntary and I can withdraw from the study at any time
without penalty.
I may be asked to participate in focus groups at certain points in the study. My
participation in such groups will be voluntary, and I can decline to participate
without compromising my involvement in the remainder of the study, or having
my records sealed.
I will be interviewed at the beginning of the study and at 6, 12, and 42 months
following the initial interview. The interview will focus on substance use,
current activities and treatment services
I will be asked to provide one urine sample at the time of the fourth interview
(42 months). My participation in the urine test will be voluntary, and I can
decline to participate without compromising my involvement in the remainder
of the study, or having my records sealed.
I do not have to answer specific questions that I might find objectionable;
There is no penalty for not providing any information;
No names, only code numbers, will appear on my interview forms or records;
The listing of assigned code numbers will be kept in a separate locked file,
accessible only to the CIRP/NDRI project research staff, with the code known
only to the Principal Investigators and the Project Director.
All written and published information will be reported as group data, with no
reference to individuals;
I will voluntarily provide you with the names and telephone numbers of persons
who will help you get in touch with me for the purpose of participating in the
research interviews and focus groups. These names and phone numbers will be
used for this purpose only.
Research staff may review my records to obtain other background and related
information, including medical/criminal information.
Research staff may obtain information regarding the following data resources:
TASC (Treatment Alternatives to Safer Communities) records
The Community Re-Entry, Inc. (CR) and Community
Assessment and Treatment Services (CATS) as well as other
treatment and service agencies
Criminal Justice records including Adult Probation Department
and Division of Parole or post release control
MACSIS database (Multi Agency Community Shared
Information System)
4

CUYAHOGA COUNTY, OHIO

CRIS (Cuyahoga Regional Information Services)
EDC (Education Development Centers, Inc.)
ODRC (Ohio Department of Rehabilitation and Correction)
Bureau of Motor Vehicles
This project does not guarantee that my criminal records will be sealed.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE BASELINE
INTERVIEW. I UNDERSTAND THAT THIS INTERVIEW IS A PART OF A RESEARCH
PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE PART.

Client’s Signature

Date

Interviewer’s Signature

Date
Client ID Number (___/___/___/___/___/___/___/___)

5

FORM APPROVED
OMB No. 0930-0248
CUYAHOGA COUNTY, OHIO Expires 10/31/06

See burden statement for follow up questionnaires

Program Rehabilitation and Restitution (PRR) Project Consent Form
Prison/Jail Consent Form
Baseline and Follow-up Interviews– Client Information Sheet
About This Study
You have previously volunteered to participate in the Program Rehabilitation and
Restitution Project. The project is a study about the benefits to people when they are
offered the opportunity to have the stigma of a criminal record removed. In the State of
Ohio, first time non-violent felons who have not been convicted of: An offense that
carries a mandatory prison term, most sex offenses, traffic offenses including Driving
while under the influence of Alcohol and/or Drugs (DUI), Driving Under License
Suspension (DUS), any other offense of violence, crimes against a minor, or any first or
second degree felony may have their records sealed after three years post supervision and
at the discretion of a judge if they have not committed any additional offenses during that
time. This opportunity is open to all eligible first time non-violent felons regardless of
whether they participate in this study. However, if you do participate in the study, there
may be an opportunity to get more case management and treatment services that possibly
may help you to keep a clean record and achieve having your records sealed. Please ask
the person interviewing you to explain anything you don’t understand. To help you, we
will read through the information together.
Involvement in the Project
We need your help in conducting the study, but your involvement in this study is up
to you. Please understand that your participation is voluntary and you are free not to take
part in the study, now or later. You are free to withdraw from the study at any time. If
you choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled; your decision will not affect your receiving the treatment or
the services you would have received if you had not been asked to participate in the
study. Also, your participation in the study will not affect your release from prison. It
will not shorten or lengthen your sentence. That is entirely separate from your
participation in the study.
Unfortunately, we cannot compensate you for your participation in this current
interview due to the fact that you are incarcerated. However, you will be compensated
for any future interviews conducted upon your release.
Description of the Project
This study is supported by the federal government, namely the Center for Substance
Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services
Administration (SAMHSA). The evaluation is under the direction of the Center for the
Integration of Research and Practice (CIRP) at the National Development and Research
Institutes, Inc. (NDRI). The reason for this study is to help people like you to get their
criminal records sealed and reduce the stigma of a criminal record. The research will
help us understand the types of programs that work best to help individuals rehabilitate
and return to the community, and the information you provide may lead to positive
changes in agencies that aim to rehabilitate offenders.

Page 1

4/7/200612/1/2003

CUYAHOGA COUNTY, OHIO

Your Role in the Study
As part of the study, you may receive additional treatment services beyond those
normally provided, such as additional case management, substance abuse treatment, and
other services. Participation in this study is voluntary, but we hope you will want to help
with this important study. The information that you give us will be used for research
purposes only and will not be shared with any other agency. If you decide to continue
volunteering, you will be asked questions about yourself and what is happening in your
life, including your health, substance use, mental health, current and past housing, and
use of the services to which you are referred. In addition to the interviews, we will also
collect some information about you from TASC files, probation, parole or post release
control, program providers, and state agencies that collect information on the use of
treatment programs and other services.
In addition to being interviewed, you may be asked to be in a focus group. You do
not have to be in the focus group to be in the study. We will also ask your consent to
audio-tape the focus group. No last names will be used in the focus group to protect the
identity of the participants. Should you decide to participate in any focus groups while
you are incarcerated we will not be able to compensate you.
This project is designed to help you to increase the chances of sealing your criminal
records, but does not guarantee that your records will be sealed. There are many reasons
why your record may not become eligible for sealing. Some examples include a record
of past/prior incarcerations; an incomplete history of past arrests or incarceration in the
State of Ohio or other states, the judge reviews your record and feels that you have not
met the necessary criteria.
Potential Risks and How You Are Protected
The risks of the study are relatively small and the benefits are high. During the
course of the interviews, participants may become concerned about the consequences of
their past drug use or difficulties with maintaining abstinence and express a need for
help/services.
A. Distress
There is a possibility that some of the questions in the interviews may make you feel
uncomfortable. Some of the questions are about troubling events that you may have had
in your life. Some people feel upset when they have to recall troubling events in their
lives. If you feel uncomfortable, we can do any of the following: you can choose not to
answer certain questions; you can take a break and continue later; or you can choose to
stop the interview. Your case manager and other staff members will be available to make
sure you have someone to help or assist you.
B. Identity
The risk of your identity being revealed is minimal because we have taken great efforts with your
records to comply with confidentiality standards to protect your identity. The information gathered about
you, including your answers to the interview questions, will be stored in secured files, and you will be
identified only by code numbers. The Principal Investigators, Dr. Harry Wexler and Dr. Gerald Melnick
will keep a logbook of names and code numbers in a locked file that only they and the Project Director can
open. The locked file will be kept at NDRI offices in New York City. Only information about the whole
group will be reported out, and it will not be possible to identify any one person. Project staff is also
carefully trained to maintain strict confidentiality in order to protect your privacy.

C. Confidentiality
Page 2

4/7/200612/1/2003

CUYAHOGA COUNTY, OHIO

Because we have taken steps to protect your confidentiality, the risk of unauthorized
disclosure is minimal. To help keep information about you private and confidential, we
have applied for a Confidentiality Certificate from the Federal agency giving us money
for the study, the Department of Health and Human Services. This certificate means that
we cannot be forced to give information about you from the research interviews and
focus groups to others, even if a court has ordered us to do so using a subpoena.
However, if you say you have been harming or abusing a child or an elderly person, we
will be required to report that. If you tell us you are going to physically hurt yourself or
someone else, we will contact someone who can help. If you commit a crime on our
treatment premises or against a treatment service provider, we will report such incidences
to the proper authorities. There is also a possibility that the agency giving us money for
this study will want to do an audit, that is, check to see if we are using the grant money
the right way. If they do an audit, we have to let them see any files they need, including
files that contain your information although they may use this information only for the
purposes of the audit. Also, the Certificate does not prevent you or your family from
releasing information about yourself or your involvement in this research.
Also, you can give permission to let people know that you are in the study. If you
have any questions about the interview, please ask the person who is interviewing you.
You can also call the evaluators at National Development and Research Institutes, Inc. to
talk more about the session. If you have questions about the study or feel you have been
hurt by the study, you may call Harry K. Wexler, Ph.D. (212.845.4400), who is in charge
of the study. If you have questions about your rights as someone who is taking part in
this study, you can call Fred Streit, Executive Director/ CEO of NDRI (212.845.4444).
Other Information about You
We will also ask you to give us the names and telephone numbers of people who can help
us get in touch with you for the purpose of your participating in the interviews or focus
groups. We will only contact these people if we can’t reach you at the phone number and
address you have given us for yourself and they will be told only that we are attempting
to locate you because you are part of the EDC study.
If there are any questions you find objectionable, we would prefer that you do not
answer them rather than give false answers.
Please sign the form stating that you understand the purpose of this interview. This
agreement will be valid for the duration of the study.

Page 3

4/7/200612/1/2003

CUYAHOGA COUNTY, OHIO

Program Rehabilitation and Restitution Project (PRR)
Informed Consent Client Signature Form

Prison/Jail Form
I, ________________________________________________, hereby give my consent
and understand the Client Information Sheet and the informed consent form including the
description of the study and its possible benefits, my role in the study, the possible risks,
and the steps taken to protect me. I understand the following:
My participation is voluntary and I can withdraw from the study at any time
without penalty.
I may be asked to participate in focus groups at certain points in the study. My
participation in such groups will be voluntary, and I can decline to participate
without compromising my involvement in the remainder of the study, or having
my records sealed.
I will be interviewed at the beginning of the study and at 6, 12, and 42 months
following the initial interview. The interview will focus on substance use,
current activities and treatment services
I do not have to answer specific questions that I might find objectionable;
There is no penalty for not providing any information;
No names, only code numbers, will appear on my interview forms or records;
The listing of assigned code numbers will be kept in a separate locked file,
accessible only to the CIRP/NDRI project research staff, with the code known
only to the Principal Investigators and the Project Director.
All written and published information will be reported as group data, with no
reference to individuals;
I will voluntarily provide you with the names and telephone numbers of persons
who will help you get in touch with me for the purpose of participating in the
research interviews and focus groups. These names and phone numbers will be
used for this purpose only.
Research staff may review my records to obtain other background and related
information, including medical/criminal information.
Research staff may obtain information regarding the following data resources:
TASC (Treatment Alternatives to Safer Communities) records
The Community Re-Entry, Inc. (CR) and Community
Assessment and Treatment Services (CATS) as well as other
treatment service agencies
Criminal Justice records including Adult Probation Department
and Division of Parole or post release control
MACSIS database (Multi Agency Community Shared
Information System)
CRIS (Cuyahoga Regional Information Services)
EDC (Education Development Centers, Inc.)
ODRC (Ohio Department of Rehabilitation and Correction)
Bureau of Motor Vehicles
Page 4

4/7/200612/1/2003

CUYAHOGA COUNTY, OHIO

This project does not guarantee that my criminal records will be sealed.
I understand that my participation in this interview will have no bearing on my
release from prison. It will not shorten or increase my current sentence.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE BASELINE
INTERVIEW. I UNDERSTAND THAT THIS INTERVIEW IS A PART OF A RESEARCH
PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE PART.

Client’s Signature

Interviewer’s Signature

Date

Date
Client ID Number (___/___/___/___/___/___/___/___)

Page 5

4/7/200612/1/2003

FORM APPROVED

CLERMONT COUNTY, OHIO OMB No. 0930-0248
Expires 10/31/06

See burden statement for baseline questionnaire

Program Rehabilitation and Restitution (PRR) Project Consent Form
Baseline and Follow-up Client Information Sheet
for Non Incarcerated Clients
About This Study
You are being asked to participate in a study about the benefits to people when they
are offered the opportunity to have the stigma of a criminal record removed. In the State
of Ohio, first time non-violent felons who have not been convicted of: An offense that
carries a mandatory prison term, most sex offenses, traffic offenses including Driving
while under the influence of Alcohol and/or Drugs (DUI), Driving Under License
Suspension (DUS), any other offense of violence, crimes against a minor, or any first or
second degree felony may have their records sealed after three years post supervision and
at the discretion of a judge if they have not committed any additional offenses during that
time. This opportunity is open to all eligible first time non-violent felons regardless of
whether they participate in this study. However, if you do participate in the study, there
may be an opportunity to get more case management and treatment services that possibly
may help you to keep a clean record and achieve having your records sealed. Please ask
the person interviewing you to explain anything you don’t understand. To help you, we
will read through the information together.
Involvement in the Project
We need your help in conducting the study, but your involvement in this study is up
to you. Please understand that your participation is voluntary and you are free not to take
part in the study, now or later. You are free to withdraw from the study at any time. If
you choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled; your decision will not affect your receiving the treatment or
the services you would have received if you had not been asked to participate in the
study.
Description of the Project
This study is supported by the federal government, namely the Center for Substance
Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services
Administration (SAMHSA). The evaluation is under the direction of the Center for the
Integration of Research and Practice (CIRP) at the National Development and Research
Institutes, Inc. (NDRI). The reason for this study is to help people like you to get their
criminal records sealed and reduce the stigma of a criminal record. The research will
help us understand the types of programs that work best to help individuals rehabilitate
and return to the community, and the information you provide may lead to positive
changes in agencies that aim to rehabilitate offenders.
Your Role in the Study
As part of the study, you may receive additional treatment services beyond those
normally provided, such as additional case management, substance abuse treatment, and
other services. Participation in this study is voluntary, but we hope you will want to help
with this important study. The information that you give us will be used for research
purposes only and will not be shared with any other agency. If you decide to be in this
study, you will be asked to participate in four research interviews, which you will be
compensated for with the exception of any interviews conducted in prison. The first
interview will take place in approximately 14 days from today. The other interviews will
1

CLERMONT COUNTY, OHIO

be conducted 6 months from now, 12 months from now, and then 42 months from now to
see how you do in the future. Each interview will take one hour-and-a-half to two hours.
A research staff member will conduct the interview. If you decide to volunteer, you will
be asked questions about yourself and what is happening in your life, including your
health, substance use, mental health, current and past housing, and use of the services to
which you are referred. In addition to the interviews, we will also collect some
information about you from TASC files, probation, parole or post release control,
program providers, and state agencies that collect information on the use of treatment
programs and other services.
You are helping us by participating in the study. In return for your assistance, we will
provide gift certificates to local stores valued at $20 for your first interview, $25 for the
second interview, $30 for the third interview, and $35 for the fourth interview.
Furthermore, at the time of the fourth interview you will also be asked to provide a urine
sample for research purposes. Your participation in the urine drug test is voluntary and
results will be kept confidential. You will be compensated an additional $10 for
providing a urine sample. Therefore, if you complete the fourth interview and participate
in the urine test, you will be provided a gift certificate with a total value of $45. You do
not need to participate in the urine drug test in order to participate in this study. You do
not need to decide now whether you would like to volunteer for the urine test. At the
time of the fourth interview the researcher will review the terms with you again and have
you sign a separate consent form should you volunteer to participate in a urine drug test.
In addition to being interviewed, you may be asked to be in a focus group. You do
not have to be in the focus group to be in the study; however, if you decide to do it, you
will be provided with a gift certificate valued at $35 for any focus group that you attend.
We will also ask your consent to audio-tape the focus group. No last names will be used
in the focus group to protect the identity of the participants. We will not be able to
compensate you for any focus groups that you participate in while incarcerated.
This project is designed to help you to increase the chances of sealing your criminal
records, but does not guarantee that your records will be sealed. There are many reasons
why your record may not become eligible for sealing. Some examples include a record
of past/prior incarcerations; an incomplete history of past arrests or incarceration in the
State of Ohio or other states, the judge reviews your record and feels that you have not
met the necessary criteria.
Potential Risks and How You Are Protected
The risks of the study are relatively small and the benefits are high. During the
course of the interviews, participants may become concerned about the consequences of
their past drug use or difficulties with maintaining abstinence and express a need for
help/services.
A. Distress
There is a possibility that some of the questions in the interviews may make you feel
uncomfortable. Some of the questions are about troubling events that you may have had
in your life. Some people feel upset when they have to recall troubling events in their
lives. If you feel uncomfortable, we can do any of the following: you can choose not to
answer certain questions; you can take a break and continue later; or, you can choose to
stop the interview. Your case manager and other staff members will be available to make
sure you have someone to help or assist you.

2

CLERMONT COUNTY, OHIO

B. Identity
The risk of your identity being revealed is minimal because we have taken great
efforts with your records to comply with confidentiality standards to protect your
identity. The information gathered about you, including your answers to the interview
questions, will be stored in secured files, and you will be identified only by code
numbers. The Principal Investigators, Dr. Harry Wexler and Dr. Gerald Melnick will
keep a logbook of names and code numbers in a locked file that only they and the Project
Director can open. The locked file will be kept at NDRI offices in New York City. Only
information about the whole group will be reported out, and it will not be possible to
identify any one person. Project staff is also carefully trained to maintain strict
confidentiality in order to protect your privacy.
Confidentiality
Because we have taken steps to protect your confidentiality, the risk of unauthorized
disclosure is minimal. To help keep information about you private and confidential, we
have applied for a Confidentiality Certificate from the Federal agency giving us money
for the study, the Department of Health and Human Services. This certificate means that
we cannot be forced to give information about you from the research interviews and
focus groups to others, even if a court has ordered us to do so using a subpoena.
However, if you say you have been harming or abusing a child or an elderly person, we
will report that. If you tell us you are going to physically hurt yourself or someone else,
we will contact someone who can help. If you commit a crime on our treatment premises
or against a treatment service provider, we will report such incidences to the proper
authorities. There is also a possibility that the agency giving us money for this study will
want to do an audit, that is, check to see if we are using the grant money the right way. If
they do an audit, we have to let them see any files they need, including files that contain
your information although they may use this information only for the purposes of the
audit. Also, the Certificate does not prevent you or your family from releasing
information about yourself or your involvement in this research.
C.

Also, you can give permission to let people know that you are in the study. If you have
any questions about the interview, please ask the person who is interviewing you. You
can also call the evaluators at National Development and Research Institutes, Inc. to talk
more about the session. If you have questions about the study or feel you have been hurt
by the study, you may call Harry K. Wexler, Ph.D. (212.845.4400), who is in charge of
the study. If you have questions about your rights as someone who is taking part in this
study, you can call Fred Streit, Executive Director/ CEO of NDRI (toll free
888.845.4695).
Other Information about You
We will also ask you to give us the names and telephone numbers of people who can
help us get in touch with you for the purpose of your participating in the interviews or
focus groups. We will only contact these people if we can’t reach you at the phone
number and address you have given us for yourself and they will be told that we are
attempting to locate you because you are part of a health study being conducted by EDC.
If there are any questions you find objectionable, we would prefer that you do not
answer them rather than give false answers.
Please sign the form stating that you understand the purpose of this interview. This
agreement will be valid for the duration of the study.
3

CLERMONT COUNTY, OHIO

Program Rehabilitation and Restitution Project (PRR)
Informed Consent Client Signature Form

I, ________________________________________________, hereby give my consent
and understand the Client Information Sheet and the informed consent form including the
description of the study and its possible benefits, my role in the study, the possible risks,
and the steps taken to protect me. I understand the following:
My participation is voluntary and I can withdraw from the study at any time
without penalty.
I may be asked to participate in focus groups at certain points in the study. My
participation in such groups will be voluntary, and I can decline to participate
without compromising my involvement in the remainder of the study, or having
my records sealed.
I will be interviewed at the beginning of the study and at 6, 12, and 42 months
following the initial interview. The interview will focus on substance use,
current activities and treatment services
I will be asked to provide one urine sample at the time of the fourth interview
(42 months). My participation in the urine test will be voluntary, and I can
decline to participate without compromising my involvement in the remainder
of the study, or having my records sealed.
I do not have to answer specific questions that I might find objectionable;
There is no penalty for not providing any information;
No names, only code numbers, will appear on my interview forms or records;
The listing of assigned code numbers will be kept in a separate locked file,
accessible only to the CIRP/NDRI project research staff, with the code known
only to the Principal Investigators and the Project Director.
All written and published information will be reported as group data, with no
reference to individuals;
I will voluntarily provide you with the names and telephone numbers of persons
who will help you get in touch with me for the purpose of participating in the
research interviews and focus groups. These names and phone numbers will be
used for this purpose only.
Research staff may review my records to obtain other background and related
information, including medical/criminal information.
Research staff may obtain information regarding the following data resources:
TASC (Treatment Alternatives to Safer Communities) records
Treatment and service agencies
Criminal Justice records including Adult Probation Department
and Division of Parole or post release control
MACSIS database (Multi Agency Community Shared
Information System)
BWRC (Business and Workforce Resource Center of Clermont
County)
Clermont Recovery Center
4

CLERMONT COUNTY, OHIO

Northland Intervention Center
Clermont Counseling Center
Department of Job and Family Services
ODRC (Ohio Department of Rehabilitation and Correction)
Department of Motor Vehicles
This project does not guarantee that my criminal records will be sealed.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE BASELINE
INTERVIEW. I UNDERSTAND THAT THIS INTERVIEW IS A PART OF A RESEARCH
PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE PART.

Client’s Signature

Interviewer’s Signature

Date

Date
Client ID Number (___/___/___/___/___/___/___/___)

5

FORM APPROVED
OMB No. 0930-0248
CLERMONT COUNTY, OHIO Expires 10/31/06

See burden statement for follow up questionnaires

Program Rehabilitation and Restitution (PRR) Project Consent Form
Prison/Jail Consent Form
Baseline and Follow-up Interviews– Client Information Sheet
About This Study
You have previously volunteered to participate in the Program Rehabilitation and
Restitution Project. The project is a study about the benefits to people when they are
offered the opportunity to have the stigma of a criminal record removed. In the State of
Ohio, first time non-violent felons who have not been convicted of: An offense that
carries a mandatory prison term, most sex offenses, traffic offenses including Driving
while under the influence of Alcohol and/or Drugs (DUI), Driving Under License
Suspension (DUS), any other offense of violence, crimes against a minor, or any first or
second degree felony may have their records sealed after three years post supervision and
at the discretion of a judge if they have not committed any additional offenses during that
time. This opportunity is open to all eligible first time non-violent felons regardless of
whether they participate in this study. However, if you do participate in the study, there
may be an opportunity to get more case management and treatment services that possibly
may help you to keep a clean record and achieve having your records sealed. Please ask
the person interviewing you to explain anything you don’t understand. To help you, we
will read through the information together.
Involvement in the Project
We need your help in conducting the study, but your involvement in this study is up
to you. Please understand that your participation is voluntary and you are free not to take
part in the study, now or later. You are free to withdraw from the study at any time. If
you choose not to participate, you will not be penalized or lose any benefits to which you
would otherwise be entitled; your decision will not affect your receiving the treatment or
the services you would have received if you had not been asked to participate in the
study. Also, your participation in the study will not affect your release from prison. It
will not shorten or lengthen your sentence. That is entirely separate from your
participation in the study.
Unfortunately, we cannot compensate you for your participation in this current
interview due to the fact that you are incarcerated. However, you will be compensated
for any future interviews conducted upon your release.
Description of the Project
This study is supported by the federal government, namely the Center for Substance
Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services
Administration (SAMHSA). The evaluation is under the direction of the Center for the
Integration of Research and Practice (CIRP) at the National Development and Research
Institutes, Inc. (NDRI). The reason for this study is to help people like you to get their
criminal records sealed and reduce the stigma of a criminal record. The research will
help us understand the types of programs that work best to help individuals rehabilitate
and return to the community, and the information you provide may lead to positive
changes in agencies that aim to rehabilitate offenders.

Page 1

4/7/2006

CLERMONT COUNTY, OHIO

Your Role in the Study
As part of the study, you may receive additional treatment services beyond those
normally provided, such as additional case management, substance abuse treatment, and
other services. Participation in this study is voluntary, but we hope you will want to help
with this important study. The information that you give us will be used for research
purposes only and will not be shared with any other agency. If you decide to continue
volunteering, you will be asked questions about yourself and what is happening in your
life, including your health, substance use, mental health, current and past housing, and
use of the services to which you are referred. In addition to the interviews, we will also
collect some information about you from TASC files, probation, parole or post release
control, program providers, and state agencies that collect information on the use of
treatment programs and other services.
In addition to being interviewed, you may be asked to be in a focus group. You do
not have to be in the focus group to be in the study. We will also ask your consent to
audio-tape the focus group. No last names will be used in the focus group to protect the
identity of the participants. Should you decide to participate in any focus groups while
you are incarcerated we will not be able to compensate you.
This project is designed to help you to increase the chances of sealing your criminal
records, but does not guarantee that your records will be sealed. There are many reasons
why your record may not become eligible for sealing. Some examples include a record
of past/prior incarcerations; an incomplete history of past arrests or incarceration in the
State of Ohio or other states, the judge reviews your record and feels that you have not
met the necessary criteria.
Potential Risks and How You Are Protected
The risks of the study are relatively small and the benefits are high. During the
course of the interviews, participants may become concerned about the consequences of
their past drug use or difficulties with maintaining abstinence and express a need for
help/services.
A. Distress
There is a possibility that some of the questions in the interviews may make you feel
uncomfortable. Some of the questions are about troubling events that you may have had
in your life. Some people feel upset when they have to recall troubling events in their
lives. If you feel uncomfortable, we can do any of the following: you can choose not to
answer certain questions; you can take a break and continue later; or you can choose to
stop the interview. Your case manager and other staff members will be available to make
sure you have someone to help or assist you.
B. Identity
The risk of your identity being revealed is minimal because we have taken great
efforts with your records to comply with confidentiality standards to protect your
identity. The information gathered about you, including your answers to the interview
questions, will be stored in secured files, and you will be identified only by code
numbers. The Principal Investigators, Dr. Harry Wexler and Dr. Gerald Melnick will
keep a logbook of names and code numbers in a locked file that only they and the Project
Director can open. The locked file will be kept at NDRI offices in New York City. Only
information about the whole group will be reported out, and it will not be possible to
identify any one person. Project staff is also carefully trained to maintain strict
confidentiality in order to protect your privacy.
Page 2

4/7/2006

CLERMONT COUNTY, OHIO

C. Confidentiality
Because we have taken steps to protect your confidentiality, the risk of unauthorized
disclosure is minimal. To help keep information about you private and confidential, we
have applied for a Confidentiality Certificate from the Federal agency giving us money
for the study, the Department of Health and Human Services. This certificate means that
we cannot be forced to give information about you from the research interviews and
focus groups to others, even if a court has ordered us to do so using a subpoena.
However, if you say you have been harming or abusing a child or an elderly person, we
will be required to report that. If you tell us you are going to physically hurt yourself or
someone else, we will contact someone who can help. If you commit a crime on our
treatment premises or against a treatment service provider, we will report such incidences
to the proper authorities. There is also a possibility that the agency giving us money for
this study will want to do an audit, that is, check to see if we are using the grant money
the right way. If they do an audit, we have to let them see any files they need, including
files that contain your information although they may use this information only for the
purposes of the audit. Also, the Certificate does not prevent you or your family from
releasing information about yourself or your involvement in this research.
Also, you can give permission to let people know that you are in the study. If you
have any questions about the interview, please ask the person who is interviewing you.
You can also call the evaluators at National Development and Research Institutes, Inc. to
talk more about the session. If you have questions about the study or feel you have been
hurt by the study, you may call Harry K. Wexler, Ph.D. (212.845.4400), who is in charge
of the study. If you have questions about your rights as someone who is taking part in
this study, you can call Fred Streit, Executive Director/ CEO of NDRI (212.845.4444).
Other Information about You
We will also ask you to give us the names and telephone numbers of people who can help
us get in touch with you for the purpose of your participating in the interviews or focus
groups. We will only contact these people if we can’t reach you at the phone number and
address you have given us for yourself and they will be told only that we are attempting
to locate you because you are part of the EDC study.
If there are any questions you find objectionable, we would prefer that you do not
answer them rather than give false answers.
Please sign the form stating that you understand the purpose of this interview. This
agreement will be valid for the duration of the study.

Page 3

4/7/2006

CLERMONT COUNTY, OHIO

Program Rehabilitation and Restitution Project (PRR)
Informed Consent Client Signature Form

Prison/Jail Form
I, ________________________________________________, hereby give my consent
and understand the Client Information Sheet and the informed consent form including the
description of the study and its possible benefits, my role in the study, the possible risks,
and the steps taken to protect me. I understand the following:
My participation is voluntary and I can withdraw from the study at any time
without penalty.
I may be asked to participate in focus groups at certain points in the study. My
participation in such groups will be voluntary, and I can decline to participate
without compromising my involvement in the remainder of the study, or having
my records sealed.
I will be interviewed at the beginning of the study and at 6, 12, and 42 months
following the initial interview. The interview will focus on substance use,
current activities and treatment services
I do not have to answer specific questions that I might find objectionable;
There is no penalty for not providing any information;
No names, only code numbers, will appear on my interview forms or records;
The listing of assigned code numbers will be kept in a separate locked file,
accessible only to the CIRP/NDRI project research staff, with the code known
only to the Principal Investigators and the Project Director.
All written and published information will be reported as group data, with no
reference to individuals;
I will voluntarily provide you with the names and telephone numbers of persons
who will help you get in touch with me for the purpose of participating in the
research interviews and focus groups. These names and phone numbers will be
used for this purpose only.
Research staff may review my records to obtain other background and related
information, including medical/criminal information.
Research staff may obtain information regarding the following data resources:
TASC (Treatment Alternatives to Safer Communities) records
Treatment and service agencies
Criminal Justice records including Adult Probation Department
and Division of Parole or post release control
MACSIS database (Multi Agency Community Shared
Information System)
BWRC (Business and Workforce Resource Center of Clermont
County)
Clermont Recovery Center
Northland Intervention Center
Clermont Counseling Center
Page 4

4/7/2006

CLERMONT COUNTY, OHIO

Department of Job and Family Services
ODRC (Ohio Department of Rehabilitation and Correction)
Department of Motor Vehicles
This project does not guarantee that my criminal records will be sealed.
I understand that my participation in this interview will have no bearing on my
release from prison. It will not shorten or increase my current sentence.
I HAVE READ THE ABOVE AND UNDERSTAND THE PURPOSE OF THE BASELINE
INTERVIEW. I UNDERSTAND THAT THIS INTERVIEW IS A PART OF A RESEARCH
PROJECT IN WHICH I HAVE VOLUNTARILY AGREED TO TAKE PART.

Client’s Signature

Interviewer’s Signature

Date

Date
Client ID Number (___/___/___/___/___/___/___/___)

Page 5

4/7/2006

FORM APPROVED
OMB No. 0930-0248
Expires 10/31/06

See burden statement on 42-month questionnaire

Program Rehabilitation and Restitution Project
Informed Consent to Conduct Urine Toxicology Test
for Non-Incarcerated Clients
Client Signature Form
I give my consent to the staff of the Program Rehabilitation and Restitution Project for
my participation in a urine toxicology test (urine drug test) as part of the Program
Rehabilitation and Restitution research interview. The purpose of the urine toxicology
test is to verify the information about recent alcohol and drug use provided during the
interview.
The sample will be identified by code numbers only; my name will not appear on the
container. The sample will be sent to a private lab for testing and the results will be sent
directly to the Project research staff in New York. This confidential information will not
be shared with treatment program staff or any other government agency. When received,
the urine toxicology test results will be stored in locked cabinets along with the interview
data, when not in use.
I understand that I can refuse to participate in the urine toxicology test at any time. My
decision regarding participation will not affect my treatment or the services I receive or
my participation in the rest of the study.
All urine toxicology test information will be destroyed three years after the completion of
the Project.

Participant Signature

Date

Interviewer’s Signature

Date
Client ID Number (___/___/___/___/___/___/___/___)

For Use in Clermont County, Ohio and Cuyahoga County, Ohio

1

APPENDIX G
INSTRUMENTS FOR INFORMATION ONLY

Computer-Assisted Intake Assessment Instrument (CIAI)................................................G1
Addiction Severity Index (ASI)..........................................................................................G2

APPENDIX H
FEDERAL REGISTER

Federal Register Notice......................................................................................................H1

APPENDIX I
LEGISLATION

42 USC 290aa (Section 501 (d) (4) of the Public Health Service Act)...............................I1