xxx National Inmate Survey Consent to Participate in Researc

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 [100/200/300] inmates at this facility who have been randomly selected to participate. Inmates will be interviewed at 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

The questionnaire will take about 10 minutes to complete. The interviewer will provide you with the questionnaire which you will complete by yourself. The questionnaire includes 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). You will never be asked to identify anyone by name. Once you have completed the questionnaire you will seal it in an envelope and give it back to the interviewer. Neither the interviewer nor anyone at this facility will ever see your completed questionnaire.

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 stop answering the questions. 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 the questionnaire. 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 completing the questionnaire, please tell me now and I will pass it to you now.

□ Willing to complete the questionnaire.

_____________________________________________________________________________________________

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.

Signature of Person Who Obtained Consent: ______________________________________

ID Number: ________________

Date: _____/_______/_________