Attachment D NIS-C ACASI Consent Form

Bureau of Justice Statistics

National Inmate Survey

Consent to Participate in Research ,

OMB Number:

Introduction

The National Inmate Survey is a research study being done by the Bureau of Justice Statistics and RTI International, a not-for-profit research organization in North Carolina. You are one of about 300 inmates at this facility who have been randomly selected to participate. Inmates will be interviewed at about 450 facilities across the country. The purpose of this research project is to estimate the number of inmates who are sexually assaulted in prisons and jails each year.

Description of the Study

This interview will take about 30 minutes. To start, the interviewer will ask you some questions about your background, education, and reason for incarceration and enter them into the computer. Next the interviewer will show you how to use the computer and you can complete the rest of the survey on your own in privacy while the interviewer stands on the other side of or outside the room. You will be able to read the questions on the computer screen and listen to them through headphones and then enter your answers directly into the computer by touching the screen. As part of this interview, the computer will randomly decide to ask you questions from one of two questionnaires. In one questionnaire, you will be asked explicit questions about your own experiences with sex and sexual assault in this facility (such as the types of sexual acts and where they occurred). In addition, you may also be asked about your use of drugs and alcohol prior to incarceration. In the other questionnaire you will be asked about your use of drugs and alcohol prior to incarceration and treatment you may have received. Only you will know which set of questions you answered. Not even the interviewer will know unless you discuss the questions with her. You will never be asked to identify anyone by name.

Possible Risks or Discomforts

Some of the survey questions are personal and it is possible that they may make you feel uncomfortable or upset. There are no right or wrong answers and you can skip any questions you do not want to answer. If you become upset for any reason, you can ask the interviewer to stop the interview. If you want to take a break at any time during the interview, please tell the interviewer. The interviewer can also provide you with instructions for contacting a mental health counselor employed by this facility who can meet with you if you feel that would be helpful.

Benefits

You will not receive any direct benefits for participating in this study. However, the results of this study may help to improve the condition and well-being of inmates in correctional facilities across the nation.

Confidentiality

Your participation in this project is voluntary and you can stop at any time. If you choose not to participate you will not lose any benefits or services that you now receive or might receive in the future. Whether you participate or not will not affect your legal status or any decisions regarding your release from this facility in any way. Your name will never be connected with the information you provide in this interview. We will treat everything you say as private and confidential and we will not share any information you provide with anyone outside or at the facility or anyone who is not working on the project. There is, however, an exception to our promise of confidentiality. If you tell the interviewer that you intend to seriously harm yourself or a specific person, we may need to inform correctional staff.

Do you have any questions about taking part in this study?

Further Questions

You may keep a copy of this form. If you have any questions about the project, you may write to the National Inmate Survey at RTI International, P.O. Box 12194, Research Triangle Park, NC 27709-2194. If you have questions about your rights as a project participant, you can write to RTI's Office of Research Protection at the same address.

If you would like to help us with our study by participating in the interview, please tell me now and we will begin.

□ Willing to participate in the interview.

_____________________________________________________________________________________________

I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the participant.

Person Who Obtained Consent: ______________________________________

ID Number: ________________

Date: _____/_______/_________