GONA_Adult_Supporting

Attachment 2 –Key Informant GONA Participant – Adult Supporting
Documents
Document A.4: GONA Baseline Interview – Phone Script and Verbal Consent Form
Document A.5: GONA Follow-up Interview Consent Form

Evaluation of the Native Aspirations Program
Document A.4: GONA Evaluation – Baseline Interview
PHONE SCRIPT and VERBAL CONSENT FORM
Hello, my name is [INSERT NAME] and I work for Macro International Inc., a research and consulting firm.
We are conducting a study of the Native Aspirations Project on behalf of Substance Abuse and Mental
Health Services Administration (SAMHSA) in the United States Department of Health and Human Services.
American Indian and Alaska Native tribes across the United States and its Territories have received funding
to decrease risks that contribute to suicide, bullying, school violence among youth and to increase factors
that are linked to the healthy and safe development of children and their families. As part this program
evaluation, Macro International Inc. is holding in-depth phone interviews prior to attendance at a
Gathering of Native Americans (GONA) meeting in order to help SAMHSA better understand the
experience and impact of the GONA, and the impact of the Native Aspirations program on your
community. I am contacting you to request your participation in these interviews.
I’d like to obtain your verbal consent to participate in this study. Is now a good time to talk?
 Yes
 No
INTERVIEWER INSTRUCTION: If yes, continue with script below
INTERVIEWER INSTRUCTION: If no, request another time to call back and obtain consent.
Okay! You have been chosen to be an interview respondent because you are about to participate in your
community’s GONA meeting. If you agree to be interviewed, here are the things you should know:
Description of Participation
We are asking you to participate in a 20 minute phone interview with a trained interviewer who will ask
you to respond to a 6 sets of questions about how people who will participate in the GONA view and
describe their relationships in and with the community; how people in the community deal with youth
violence, bullying, substance abuse, and suicide; community members’ willingness to work with together
to address these issues; community protective factors; and how community members can work together
to address these issues.
Risks and Benefits
There will be no direct benefit to you from participating in this evaluation. The benefit of this interview to
you is that your input will help SAMHSA to build better prevention programs for tribal communities. Your
input in this interview poses few, if any, risks to you. Questions may make you feel uncomfortable or
cause you to feel emotional. You can choose not to answer any question for any reason.
Compensation
You will not receive compensation for this interview.
Confidentiality
Native Aspirations Evaluation

GONA Baseline Interview – Phone Interview & Verbal Consent

9.4.2008

All responses will be treated confidentially. We will be taking notes during the interview about what was
said, but we will not link responses to your identity. The interview will be audiotaped by the researchers
unless you request not to be audiotaped. The tape will be in the sole possession of the researchers and
will be destroyed at the end of the project. At the end of the study, we will erase the tapes and throw
them away. You can choose to be interviewed without being audiotaped. Your name and answers to these
questions will be kept private. To protect your privacy, we will keep the records and tapes in locked files
and only study staff will be allowed to use them. Your name will not be used in any reports about this
study. Only authorized people will have access to the information you provide.
In addition, to help protect the information that you give us, we have obtained a Certificate of
Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate
of Confidentiality will protect the members of the research staff from being forced, even under a
subpoena, to release any information in which you are identified. Exceptions to the Certificate of
Confidentiality are information on child abuse and neglect, or information regarding imminent danger to
yourself or others, which we will report to the appropriate local and state agency. Additionally, DHHS may
see your information if we are audited. Finally, the Certificate of Confidentiality does not imply the
endorsement or the disapproval of the Department of Health and Human Services.
Do I have your permission to record the interview?



YES
NO

You will receive a copy of this consent form via email or regular mail.
The information obtained in your interview will be used for this project. Only authorized people will have
access to the information.
Rights Regarding Decision to Participate
Participation in the interview is completely voluntary. You do not have to answer questions that you do
not want to answer. You may choose to discontinue the interview at any time, for any reason. If you
change your mind and quit, all of your answers will be destroyed if that is what you want.
Contact information
Any questions you have about this study will be answered before the interview begins. However, should
you have any concerns about your participation in this interview or have any questions about the
evaluation, please contact Christine Walrath at [email protected] or you may call her
collect (646-695-8154) or Kara Riehman at [email protected] or you may call her
collect at (404-592-2148).

Do you agree to participate in this interview?
 YES (Verbal Consent Provided)
 NO
Native Aspirations Evaluation

GONA Baseline Interview – Phone Interview & Verbal Consent

9.4.2008

[INTERVIEWER INSTRUCTION: RECORD THE FOLLOWING]
Date of consent obtained:
Time of consent obtained:
Interviewer Signature: ___________________________________________________________
[INTERVIEWER INSTRUCTION: - IF “NO” ABOVE THEN THANK THE PERSON FOR THEIR TIME AND END
THE CALL. IF “YES” ABOVE THEN STATE THE FOLLOWING:
I’m glad that you consent to be interviewed. Let’s set up a date and time most convenient for you to
conduct the 20-minute interview.
[INTERVIEWER INSTRUCTION: SCHEDULE DATE/TIME FOR THE INTERVIEW]
Date: __________________
Time: __________________ (before to specific time zone)
Also I would like to send you an electronic reminder before our interview. Can you please confirm your
name, address, phone number, and e-mail?
[INTERVIEWER INSTRUCTION: RECORD THE FOLLOWING]
NAME
MAILING ADDRESS
WORK TELEPHONE
CELL PHONE:
E-MAIL
Please contact me at [PHONE NUMBER] if your schedule changes so that we can reschedule a time to talk.
Otherwise, I look forward to talking with you on [Month/Day/Year] at [Time].
Thank you!

Native Aspirations Evaluation

GONA Baseline Interview – Phone Interview & Verbal Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document A.5: GONA Evaluation – Follow-up Interview
CONSENT FORM
Purpose of the Study
The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States
Department of Health and Human Services is studying the Native Aspirations Project. American Indian and
Alaska Native tribes across the United States and its Territories have received funding to decrease risks
that contribute to suicide, bullying, school violence among youth and to increase factors that are linked to
the healthy and safe development of children and their families. On behalf of SAMHSA, Macro
International Inc. is holding in-depth interviews following attendance at the Gathering of Native Americans
(GONA) meeting in order to help SAMHSA better understand the experience and impact of the GONA, and
the impact of the Native Aspirations program on your community.
Description of Participation
We are asking you to participate in an in-person interview with a trained interviewer who will ask you to
respond to a set of questions about the experiences of participants during the GONA; participation in
activities; views on community relationships; knowledge of the Native Aspirations Project; knowledge of
risk factors for youth violence, bullying, substance abuse, and suicide; community protective factors;
willingness of community members to work together and suggestions for working together; and next
steps. The interview includes 11 questions and will take approximately 60-90 minutes to complete. Here
are some additional things we want you to know about participating in the interview.
Risks and Benefits
There will be no direct benefit to you from participating in this evaluation. The benefit of this interview to
you is that your input will help SAMHSA to build better prevention programs for tribal communities. Your
input in this interview poses few, if any, risks to you. Questions may make you feel uncomfortable or
cause you to feel emotional. You can choose not to answer any question for any reason.
Compensation
If you agree to take part in this interview, you will receive a $20 incentive. Payment will be made to you
upon completion of the interview.
Confidentiality
All responses will be treated confidentially. We will be taking notes during the interview about what was
said, but we will not link responses to your identity. The interview will be audiotaped by the researchers
unless you request not to be audiotaped. The tape will be in the sole possession of the researchers and
will be destroyed at the end of the project. At the end of the study, we will erase the tapes and throw
them away. You can choose to be interviewed without being audiotaped. Your name and answers to these
questions will be kept private. To protect your privacy, we will keep the records and tapes in locked files
and only study staff will be allowed to use them. Your name will not be used in any reports about this
study. Only authorized people will have access to the information you provide.
Native Aspirations Evaluation

GONA Follow-up Interview – Adult Consent

9.4.2008

In addition, to help protect the information that you give us, we have obtained a Certificate of
Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate
of Confidentiality will protect the members of the research staff from being forced, even under a
subpoena, to release any information in which you are identified. Exceptions to the Certificate of
Confidentiality are information on child abuse and neglect, or information regarding imminent danger to
yourself or others, which we will report to the appropriate local and state agency. Additionally, DHHS may
see your information if we are audited. Finally, the Certificate of Confidentiality does not imply the
endorsement or the disapproval of the Department of Health and Human Services.
Rights Regarding Decision to Participate
Participation in the interview is completely voluntary. You do not have to answer questions that you do
not want to answer. You may choose to discontinue the interview at any time, for any reason. If you
change your mind and terminate the interview, all of your answers will be destroyed if that is what you
want.
Contact information
If you have any concerns about your participation in this survey or have any questions about the
evaluation, please contact Christine Walrath at [email protected] or you may call her
collect (646-695-8154) or contact Kara Riehman at [email protected] or you may
call her collect at (404-592-2148).
______ Please check here if you are willing to have the interview audiotaped.
Please sign below to indicate that you have read the above and agree to take part in this in-depth
interview.
Please print your name
Please sign your name
Date

THANK YOU

Native Aspirations Evaluation

GONA Follow-up Interview – Adult Consent

9.4.2008