Community_Adult_Supporting

Attachment 10 – Community Member, Survey – Adult Supporting Docs
Document E.3: C-KABS Adult Consent

Evaluation of the Native Aspirations Program
Document E.3: Community Knowledge, Awareness, and Behaviors – Adult Version
(C-KABS-A)
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 asking that you complete this Community Survey. The survey includes a series of
questions asking you about your community, attitudes, beliefs, and experiences. The survey also asks
about your exposure to and knowledge about suicide, bullying, violence, and substance abuse prevention.
The findings from the survey will inform SAMHSA about the impact of the Native Aspirations program on
community knowledge attitudes and behavior.
Description of Participation
You were randomly selected to respond to this survey because your community, along with other tribal
communities across the country, received federal funding to prevent violence, bullying, and suicide among
Native American youth. The survey consists of 36 questions and should take approximately 45 minutes for
you to complete. You may be asked to complete the Community Survey once per year. You may
participate up to three times.
There are no right or wrong responses to this survey. Here are some things we want you to know about
the survey prior to agreeing and consenting to participating:
Risks and Benefits
Completing this survey 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. You may chose
to cease input of information at any time or not answer a question, for whatever reason. Your
participation will not result in any direct benefits to you. However, your input will be used to help Native
American youth, Native American communities, and the Native Aspirations program.
Compensation
If you agree to take part in this evaluation, you will be placed in a lottery for [Insert community-specific
incentive].
Confidentiality
All responses will be treated confidentially. Your name and answers to these questions will be kept
private. To protect your privacy, we will keep the records 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. The information that we report will be done in aggregate,
will not contain any identifying information and your name will not be used in any reports about this
evaluation.
Native Aspirations Evaluation

C-KBAS - Adult Version Informed Consent

9.4.2008

In addition, to help protect the information that you gives 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
you 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. Refusal to participate involves no penalty or
adverse consequences. You do not have to answer questions that you do not want to answer. You may
choose to discontinue the survey 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
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 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

C-KBAS - Adult Version Informed Consent

9.4.2008