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pdfDocument C.2
TRAINING ID: PARTICIPANT ID:
OMB No. 0930-0286
Expiration Date: 05/31/10
Training Utilization and Penetration Survey
CONSENT TO CONTACT FORM
As part of the Garrett Lee Smith Youth Suicide Prevention and Early Intervention Cross-site
Evaluation, we will be interviewing individuals who participated in the training activity you just
completed. The Training Utilization and Preservation Survey is a quantitative, telephone
interview that will be administered to participants from a random sample of suicide prevention
gatekeeper training programs and collect information about gatekeeper knowledge, attitudes, and
behaviors following their trainings. If you choose to participate, your participation in this brief
survey is completely voluntary. Your answers to the survey questions will be kept private except
as otherwise required by law. Your name will not be linked with the information on your survey.
Your name will not be used in any reports about this evaluation.
We are interested in contacting you again within the next 2 months to ask you some questions
about what you learned during this training; how you have used what you learned and what
impact it has had on your identification and referral of youth at risk for suicide in your
community. Findings from the survey will assist in informing the Substance Abuse and Mental
Health Services Administration about suicide prevention activities and training experiences
The survey will take approximately 10 minutes and will be conducted over the telephone by
a member of the cross-site evaluation team. If you are selected to participate in the
interview, you will be provided with $10 in appreciation of your time.
Are you interested in being contacted about possible participation in the Training
Utilization and Penetration Key Survey?
Yes
No
If you are interested in participating in this important effort, or in learning more about the
Training Utilization and Penetration Key Survey, please provide your contact information below.
If you are selected to participate in the interview, a member of the cross-site evaluation team will
contact you to schedule an interview. Participants for the survey will be randomly selected from
a complete list of interested training participants.
Name:
TUP-S Consent To Contact Form
03.03.2010
Best Contact?
(select yes or no)
Document C.2
TRAINING ID: PARTICIPANT ID:
Home Address:
Work Address:
Home Phone:
Work Phone:
Cell Phone:
Work Email:
Personal Email:
What’s the best
time to call?
What is the best
way to reach you?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Phone
Email
If you have any concerns or questions about your participation in this study, please contact
Gingi Pica, ICF Macro at 212-941-5555.
Whether you selected yes or no above, please tear off this page and return it to the training
facilitator.
Thank you!
TUP-S Consent To Contact Form
03.03.2010
Document D.2
TRAINING ID: PARTICIPANT ID:
OMB No. 0930-0286
Expiration Date: 05/31/10
Training Utilization and Penetration Survey
CONSENT TO CONTACT FORM
As part of the Garrett Lee Smith Youth Suicide Prevention and Early Intervention Cross-site
Evaluation, we will be interviewing individuals who participated in the training activity you just
completed. The Training Utilization and Preservation Survey is a quantitative, telephone
interview that will be administered to participants from a random sample of suicide prevention
gatekeeper training programs and collect information about gatekeeper knowledge, attitudes, and
behaviors following their trainings. If you choose to participate, your participation in this brief
survey is completely voluntary. Your answers to the survey questions will be kept private except
as otherwise required by law. Your name will not be linked with the information on your survey.
Your name will not be used in any reports about this evaluation.
We are interested in contacting you again within the next 2 months to ask you some questions
about what you learned during this training; how you have used what you learned and what
impact it has had on your identification and referral of youth at risk for suicide in your
community. Findings from the survey will assist in informing the Substance Abuse and Mental
Health Services Administration about suicide prevention activities and training experiences
The survey will take approximately 10 minutes and will be conducted over the telephone by
a member of the cross-site evaluation team. If you are selected to participate in the
interview, you will be provided with $10 in appreciation of your time.
Are you interested in being contacted about possible participation in the Training
Utilization and Penetration Key Survey?
Yes
No
If you are interested in participating in this important effort, or in learning more about the
Training Utilization and Penetration Key Survey, please provide your contact information below.
If you are selected to participate in the interview, a member of the cross-site evaluation team will
contact you to schedule an interview. Participants for the survey will be randomly selected from
a complete list of interested training participants.
Name:
Home Address:
TUP-S Consent To Contact Form
03.03.2010
Best Contact?
(select yes or no)
Yes
No
Document D.2
TRAINING ID: PARTICIPANT ID:
Work Address:
Home Phone:
Work Phone:
Cell Phone:
Work Email:
Personal Email:
What’s the best
time to call?
What is the best
way to reach you?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Phone
Email
If you have any concerns or questions about your participation in this study, please contact
Gingi Pica, ICF Macro at 212-941-5555.
Whether you selected yes or no above, please tear off this page and return it to the training
facilitator.
Thank you!
TUP-S Consent To Contact Form
03.03.2010
Document D.3
OMB No. 0930-0286
Expiration Date: 05/31/10
Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS) State/Tribal and Campus Youth
Suicide Prevention and Early Intervention Programs
Training Utilization and Preservation - Survey
On [date of training] you participated in a training called [insert training name], as part of the
Garrett Lee Smith Memorial (GLS) State/Tribal and Campus Youth Suicide Prevention Program.
At the end of the program, you consented to be contacted for a follow up survey. We are
contacting you now to administer the survey. This survey asks questions about the training, what
you plan to do with what you learned during the training, and your satisfaction with the training.
Findings from this survey will help inform the Substance Abuse and Mental Health Services
Administration (SAMHSA) about suicide prevention activities.
The survey will take approximately 10 minutes. Your participation in this survey is
completely voluntary; and you may end the interview at any time. Your answers to the survey
questions will never be associated with your name or your organization You may ask any
questions that you have before, during or after you complete the survey. May we begin now?
Privacy: The information that we report to SAMSHA will not contain your name. Your name
will not be used in any reports about this evaluation.
Procedures: All participants in training activities funded as part of your State’s Youth Suicide
Prevention Program are being asked to complete this survey. Therefore, your participation is
very important. The survey questions will ask you about your participation in [INSERT
TRAINING NAME].
Risks: There are few, if any, risks to you by completing this survey. You may stop the survey at
any time or not answer a question. You will not be penalized for stopping. If you stop the
survey, at your request, we will destroy your survey. Any questions that you have about this
survey will be answered before you start the survey.
Contact information: If you have any concerns about completing this survey or have any
questions about the study, please contact Christine Walrath, Principal Investigator, at 212-941-5555 or
[email protected].
Thank you in advance for your willingness to participate. This call may be recorded and/or
monitored for quality assurance purposes.
| File Type | application/pdf |
| File Title | Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS) State/Tribal Youth Suicide Prevention and Early Intervention Pro |
| Author | Angela.K.Sheehan |
| File Modified | 2010-05-19 |
| File Created | 2010-05-19 |