ACASI Concent Card

Script to Be Read After Consent Form

Instructions to Interviewer: You must read the following script out loud to the inmate and confirm that the inmate understands the information before concluding the informed consent process.

I want to go over the main points covered in this form to make sure everything is clear.

This interview is voluntary. You can say yes or no. It is totally up to you. Nothing about your legal situation, such as when you will be released or what treatment you might receive, will be changed by whether or not you participate in this interview.

If you start the interview and then want to quit, that is okay. If you want to skip certain questions, that is okay too. Do you understand?

IF THE INMATE ANSWERS ‘NO’, ANSWER ANY QUESTIONS THE INMATE HAS AND THEN RETURN TO THE CONSENT FORM AND RE-READ THE TEXT ENTITLED RISKS AND BENEFITS AND POINT TO THIS TEXT ON THE INMATE’S COPY OF THE CONSENT FORM.

It is possible that some of the questions you answer using the computer may make you feel nervous or upset. If that happens and you want to take a break or you want to talk to someone about how the questions made you feel, you can tell me you want to take a break or want to speak with someone.

The form I just read aloud to you also talks about privacy. By private, we mean that the answers you enter into the computer, even those about being abused or harmed, will always be kept secret. No one will ever know your answers, not even me.

READ FOR JUVENILES ONLY:

However, if you tell me out loud that you are being abused at this facility I, or my supervisors, may need to report it to the agency in this state that investigates abuse. Once we make a report, we have no control over what will be done with the information.

Do you understand that what you enter into the computer, even if it is about abuse will always be kept private?

IF THE INMATE ANSWERS ‘NO’, ANSWER ANY QUESTIONS THE INMATE HAS AND THEN RETURN TO THE CONSENT FORM AND RE-READ THE TEXT ENTITLED CONFIDENTIALITY AND POINT TO THIS TEXT ON THE INMATE’S COPY OF THE CONSENT FORM.

Do you understand that if you say something out loud about being abused, that information is not secret and may be reported to a state agency?

IF THE INMATE ANSWERS ‘NO’, ANSWER ANY QUESTIONS THE INMATE HAS AND THEN RETURN TO THE CONSENT FORM AND RE-READ THE TEXT ENTITLED CONFIDENTIALITY AND POINT TO THIS TEXT ON THE INMATE’S COPY OF THE CONSENT FORM.

So, please do not say anything out loud to me about being abused unless you want me to pass that information on to the agency in this state that investigates abuse. Do you have any questions?

If you think of any questions or comments about the survey later, you can write us at the address provided. If you would like to participate in the interview, please tell me now and we will begin.