Community_Readiness_Supporting

Attachment 14 – Key informant, Community Readiness Supporting Docs:
Document C.2: Community Readiness Assessment Phone Script and Verbal Consent
Document C.3: Community Readiness Assessment Written Consent

Evaluation of the Native Aspirations Project
Document C.2: Community Readiness Assessment
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 of this program
evaluation, Macro International Inc. is holding in-depth phone interviews in year 1 and year 3 of your
Native Aspirations Project. The interview includes questions which address six areas focused on an
identified social concern (i.e., youth violence, bullying, and suicide). These areas include (a) community
prevention efforts, (b) community knowledge of prevention efforts, (c) leadership, (d) community climate,
(e) knowledge about the problem, and (f) resources for prevention efforts. The findings from the survey
will inform the community and SAMHSA of your community’s overall readiness score and your
community’s status as it relates to the six areas. 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 were selected to participate in this interview because you were identified as a key person in
your community working to reduce youth violence. If you agree to be interviewed, here are the things you
should know:
Description of Participation
We are asking you to participate in a 60 minute phone interview with a trained interviewer who will ask
you to respond to a set of questions about American Indian/Alaska Native youth violence. You may be
asked to participate in the interview up to two times, now and 2 years from now. Here are some 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. Your input in this interview
poses few, if any, risks to you. You can choose not to answer any question for any reason.
Compensation
If you agree to take part in this evaluation, you will not be compensated for this interview.
Native Aspirations Evaluation

Community Readiness Assessment - Phone Script and Verbal Consent

9.4.2008

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.
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.
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 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 contact 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
[INTERVIEWER INSTRUCTION: RECORD THE FOLLOWING]
Native Aspirations Evaluation

Community Readiness Assessment - Phone Script and Verbal Consent

9.4.2008

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

Community Readiness Assessment - Phone Script and Verbal Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document C.3: Community Readiness Assessment
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 program. 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 in year 1 and year 3 of your Native Aspirations project.
The interview includes questions which addresses six dimensions focused on an identified social concern
(i.e., youth violence, bullying, and suicide). These dimensions include (a) community prevention efforts, (b)
community knowledge of prevention efforts, (c) leadership, (d) community climate, (e) knowledge about
the problem, and (f) resources for prevention efforts. The findings from the survey will inform SAMHSA of
each communities overall readiness score and each communities status as it relates to the six dimensions.
Description of Participation
You selected to participate in this interview because you were identified as a key person in your
community working to reduce youth violence. We are asking you to participate in a 60 minute phone
interview with a trained interviewer who will ask you to respond to a set of questions about American
Indian/Alaska Native youth violence. You may be asked to participate in the interview up to two times, in
year 1 and year 3 of the grant. Here are some 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. Your input in this interview
poses few, if any, risks to you. You can choose not to answer any question for any reason.
Compensation
If you agree to take part in this evaluation, you will receive a $20 incentive.
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 audio taped 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

Community Readiness Assessment - 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.
The information that you provide in this interview will be kept confidential except otherwise required by
law. Any identifying information will not be disclosed to anyone but the researchers conducting this
evaluation. The information that we report to SAMHSA will be reported in aggregate, will not contain any
identifying information and your name will not be used in any reports about this evaluation.
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 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
If 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 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

Community Readiness Assessment - Adult Consent

9.4.2008