Community_Supporting

Attachment 6 – Key Informant Community Plan Supporting Documents
Document B.4: Community Plan Focus Group Adult Consent
Document B.7: Community Plan In-Depth Interviews Version 1 Adult Consent
Document B.8: Community Plan In-Depth Interviews Version 2 Adult Consent
Document B.5: Community Plan Youth Focus Groups Caregiver Consent
Document B.6: Community Plan Focus Groups Youth Assent
Document B.9: Community Plan Interview Version 1 Caregiver Consent
Document B10: Community Plan Interview Version 1 Youth Assent
Document B.11: Community Plan Interview Version 2 Caregiver Consent
Document B.12 Community Plan Interview Version 2 Youth Assent

Evaluation of Native Aspirations Project
Document B.4: Community Plan Evaluation – Focus Group
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 focus groups to attendees involved in Community Mobilization and Planning
(CMP) in order to help SAMHSA better understand the development, and implementation of community
plans.
Description of Participation
You were asked to participate because you have been involved in developing the community mobilization
plan for the Native Aspirations Project in your community. In the focus group we will ask you 7 sets of
items about the community mobilization planning process, early implementation of the plan, and
organizational and community awareness and involvement. The focus group should take approximately
60-90 minutes. If you decide to join in the discussion, here are some things you should know:
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 discussion group, you will receive a $20 incentive. Payment will be made
to you upon completion of the discussion group.
Confidentiality
All responses will be treated confidentially. We will be taking notes during the focus group about what was
said, but we will not link responses to your identity. The focus group 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 participate 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
Native Aspirations Evaluation

CMP Focus Group – Adult Consent

9.4.2008

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.
Contact information
If you have any concerns about your participation in this discussion group 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).
Rights Regarding Participation
Your participation is totally voluntary. You may discontinue participation at any time, either by leaving the
discussion group or not answering a question.
Voluntary Consent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered prior to the beginning of the focus group. A copy of this form will be given to me. By signing my
name below, I freely agree to be in the study.
______ Please check here if you are willing to have the interview audiotaped.

Print your name:

_________________________

Date:

__________________

Signature:

_________________________

Witness: __________________

THANK YOU

Native Aspirations Evaluation

CMP Focus Group – Adult Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.7: Community Plan In-depth Interviews –
Version 1 - Active Team Members
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 during the third year of the Native Aspirations grant in
order to help SAMHSA better understand the process for development, and implementation, of
community plans in the years succeeding the Community Mobilization and Planning (CMP) meeting.
Description of Participation
We are asking you to participate in a 60-minute in-person interview with a trained interviewer who will
ask you to respond to a set of questions about the CMP implementation process; organizational and
community awareness and involvement with Native Aspirations; and the impact of the Native Aspirations
program on the community. You were chosen to participate in this interview because you remained active
in your community’s mobilization and planning process.
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. 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

CMP In-Depth Interview - V1 – 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 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 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

CMP In-Depth Interview - V1 – Adult Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.8: Community Plan In-depth Interviews –
Version 2 – Former Team Members
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 during the third year of the Native Aspirations grant in
order to help SAMHSA better understand the process for development, and implementation, of
community plans in the years succeeding the Community Mobilization and Planning (CMP) meeting.
Description of Participation
We are asking you to participate in a 20-minute in-person interview with a trained interviewer who will
ask you to respond to a set of questions about the CMP implementation process; organizational and
community awareness and involvement with Native Aspirations; and the impact of the Native Aspirations
program on the community. You were chosen to participate in this interview because of your role as a
former team member in your community’s Native Aspirations project. 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. 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. 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
Native Aspirations Evaluation

CMP In-Depth Interview – V2 – Adult Consent

9.4.2008

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.
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
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

CMP In-Depth Interview - V1 – Adult Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.5: Community Plan Evaluation – Focus Group
Caregiver Consent
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 focus groups to attendees involved in Community Mobilization and Planning
(CMP) in order to help SAMHSA better understand the development, and implementation of community
plans.
Description of Participation
We will ask your child 7 sets of questions about the community mobilization planning process, what the
status of the plan is, and what needs to happen next. We would also like to find out how the process has
been going in these first months. Your child was asked to participate because s/he has been involved in
developing the community mobilization plan for the Native Aspirations Project in your community. The
group will last about 60-90 minutes.
Risks and Benefits
There are no direct benefits to your child for participating in this discussion group, but s/he is helping to
build better programs for tribal communities. Risks are considered to be minimal and include the
possibility that your child will feel uncomfortable or emotional when answering questions.
Compensation
If you agree to your child’s participation in the discussion group, s/he will receive a $20 incentive. Payment
will be made to your child upon completion of the discussion group.
Confidentiality
All responses will be treated confidentially. We will be taking notes during the focus group about what was
said, but we will not link responses to your child’s identity. The focus group will be audiotaped by the
researchers unless your child requests 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. Your child can choose to participate without being audiotaped. Your child’s
name and answers to these questions will be kept private. To protect your child’s privacy, we will keep the
records and tapes in locked files and only study staff will be allowed to use them. Your child’s name will
not be used in any reports about this study. Only authorized people will have access to the information
your child provides.
In addition, to help protect the information that your child gives us, we have obtained a Certificate of
Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate
Native Aspirations Evaluation

CMP Youth Focus Group – Caregiver Consent

9.4.2008

of Confidentiality will protect the members of the research staff from being forced, even under a
subpoena, to release any information in which your child is identified. Exceptions to the Certificate of
Confidentiality are information on child abuse and neglect, or information regarding imminent danger to
themselves 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.
Contact information
If you have any concerns about your child’s participation in this discussion group 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).
Rights Regarding Participation
I understand that I or my child will not be in trouble if I do not want my child to be a part of this discussion
group or if I or my child decides to quit after it has started. My child does not have to answer questions
that s/he does not want to answer. If I change my mind about my child’s participation, or if my child
changes her/his mind and quits, all of my child’s answers to questions will be destroyed, if that is what I
want. No one will say that I or my child can’t be in other projects because I don’t want my child to be in
this study or my child does not want to be in this study.
Caregiver Consent
By signing my name below, I freely agree to allow my child to participate in this discussion group and for
the discussion group to be audio-recorded. I read this form or it has been read to me. I understand what it
says. I have been asked if I have any questions and my questions (if any) have been answered.
I, ______________________________________, have read the above, or it has been read to me. My child
may participate. (Caregiver/Guardian)
Guardian’s Signature: _________________________

Date:

_________________

THANK YOU

Native Aspirations Evaluation

CMP Youth Focus Group – Caregiver Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.6: Community Plan Evaluation – Focus Group
Youth Assent
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. Macro International Inc. is working with
SAMHSA on this project, and is holding focus groups to attendees involved in Community Mobilization and
Planning (CMP) in order to help SAMHSA better understand the development, and implementation of
community plans.
Description of Participation
We will ask you 7 sets of questions about the community mobilization planning process; where you are
with the plan and what needs to happen next. We would also like to find out how the process has been
going in these first months. You were asked to participate because you have been involved in developing
the community mobilization plan for the Native Aspirations Project in your community. The discussion
group will last about 60-90 minutes.
Risks and Benefits
There are no direct benefits to you for participating in this discussion group, but you are helping to build
better programs for tribal communities. Risks may include feeling uncomfortable or emotional when
answering questions.
Payment
If you agree to participate in the discussion group, you will receive a $20 incentive. Payment will be made
to you upon completion of the discussion group.
Confidentiality
All responses will be treated confidentially. We will be taking notes during the focus group about what was
said, but we will not link responses to your identity. The focus group 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 participate 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
Native Aspirations Evaluation

CMP Youth Focus Group – Youth Assent

9.4.2008

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.
Contact information
If you have any concerns about your participation in this discussion group 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).
Rights Regarding Participation
I understand that I will not be in trouble if I do not want to be a part of this focus group or if I decide to
quit after it has started. I do not have to answer questions that I do not want to answer. If I change my
mind and quit, all of my answers to questions will be destroyed, if that is what I want. No one will say that
I can’t be in other projects because I don’t want to be in this study.
Voluntary Assent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree to be in the
project.
______ Please check here if you are willing to have the interview audiotaped.
Print your name:

_________________________

Date:

__________________

Signature:

_________________________

Witness: __________________

THANK YOU

Native Aspirations Evaluation

CMP Youth Focus Group – Youth Assent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.9: Community Plan Evaluation Interview
Version 1 – Active Team Members
Caregiver Consent
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 interviews with attendees involved in Community Mobilization and Planning
(CMP) in order to help SAMHSA better understand the development, and implementation of community
plans.
Description of Participation
The interview will last about 1 hour. We will ask your child a set of questions about the community
mobilization planning process; organizational and community awareness and involvement with Native
Aspirations; and the impact of the Native Aspirations program on the community. Your child was chosen
to participate in this interview because s/he remained active in your community’s mobilization and
planning process. If you decide your child can join in the discussion, here are some things you should
know:
Compensation
If you agree to your child’s participation in the interview, s/he will receive a $20 incentive. Payment will be
made to your child 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 child’s identity. The interview will be audio taped by the
researchers unless your child requests 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. Your child can choose to participate without being audiotaped. Your child’s
name and answers to these questions will be kept private. To protect your child’s privacy, we will keep the
records and tapes in locked files and only study staff will be allowed to use them. Your child’s name will
not be used in any reports about this study. Only authorized people will have access to the information
your child provides.
In addition, to help protect the information that your child 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 s/he is identified. Exceptions to the Certificate of
Confidentiality are information on child abuse and neglect, or information regarding imminent danger to
Native Aspirations Evaluation

CMP Youth Interview – Caregiver Consent

9.4.2008

themselves 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.
Contact information
If you have any concerns about your child’s 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).
Rights Regarding Participation
I understand that I or my child will not be in trouble if I do not want my child to take part in this interview
or if I or my child decides to quit after it has started. My child does not have to answer questions that s/he
does not want to answer. If I change my mind about my child’s participation, or if my child changes her/his
mind and quits, all of my child’s answers to questions will be destroyed, if that is what I want. No one will
say that I or my child can’t be in other projects because I don’t want my child to be in this study or my
child does not want to be in this study.
Caregiver Consent
By signing my name below, I freely agree to allow my child to participate in this interview and for the
interview to be audio-recorded. I read this form or it has been read to me. I understand what it says. I
have been asked if I have any questions and my questions (if any) have been answered.
______ Please check here if you are willing to have the interview audiotaped.

I, ______________________________________, have read the above, or it has been read to me. My child
may participate. (Caregiver/Guardian)
Guardian’s Signature: _________________________

Date:

_________________

THANK YOU

Native Aspirations Evaluation

CMP Youth Interview – Caregiver Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.10: Community Plan Evaluation Interview
Version 1 – Active Team Members
Youth Assent
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. Macro International Inc. is working with
SAMHSA on this project, and is holding interviews with attendees involved in Community Mobilization and
Planning (CMP) in order to help SAMHSA better understand the development, and implementation of
community plans.
Description of Participation
The interview will last about 1 hour. We will a set of questions about the community mobilization planning
process; the community awareness about the project; and the impact of the Native Aspirations Project on
your community. You were asked to participate because you have been involved in developing the
community mobilization plan for the Native Aspirations Project in your community. If you decide to join in
the interview, here are some things you should know:
Payment
If you agree to participate in the 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 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 participate 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
you or others, which we will report to the appropriate local and state agency. Additionally, DHHS may see
Native Aspirations Evaluation

CMP Youth Interview – Youth Assent

9.4.2008

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.
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).
Rights Regarding Participation
I understand that I will not be in trouble if I do not want to be a part of this interview or if I decide to quit
after it has started. I do not have to answer questions that I do not want to answer. If I change my mind
and quit, all of my answers to questions will be destroyed, if that is what I want. No one will say that I
can’t be in other projects because I don’t want to be in this study.
Voluntary Assent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree to be in the
project.
______ Please check here if you are willing to have the interview audiotaped.

Print your name:

_________________________

Date:

__________________

Signature:

_________________________

Witness: __________________

THANK YOU

Native Aspirations Evaluation

CMP Youth Interview – Youth Assent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.11: Community Plan Evaluation Interview
Version 2 – Former Team Members
Caregiver Consent
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. 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 interviews with attendees involved in Community Mobilization and
Planning (CMP) in order to help SAMHSA better understand the development, and implementation of
community plans.
Description of Participation
The interview will last about 20 minutes. We will ask your child a set of questions about the community
mobilization planning process; organizational and community awareness and involvement with Native
Aspirations; and the impact of the Native Aspirations program on the community. Your child was chosen
to participate in this interview because s/he remained active in your community’s mobilization and
planning process. If you decide your child can join in the discussion, here are some things you should
know:
Compensation
If you agree to your child’s participation in the interview, s/he will receive a $20 incentive. Payment will
be made to your child 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 child’s identity. The interview will be audiotaped by the
researchers unless your child requests 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. Your child can choose to participate without being audiotaped. Your child’s
name and answers to these questions will be kept private. To protect your child’s privacy, we will keep the
records and tapes in locked files and only study staff will be allowed to use them. Your child’s name will
not be used in any reports about this study. Only authorized people will have access to the information
your child provides.
In addition, to help protect the information that your child 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
Native Aspirations Evaluation

CMP Youth Interview – Caregiver Consent

9.4.2008

themselves 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.
Contact information
If you have any concerns about your child’s 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).
Rights Regarding Participation
I understand that I or my child will not be in trouble if I do not want my child to take part in this interview
or if I or my child decides to quit after it has started. My child does not have to answer questions that s/he
does not want to answer. If I change my mind about my child’s participation, or if my child changes her/his
mind and quits, all of my child’s answers to questions will be destroyed, if that is what I want. No one will
say that I or my child can’t be in other projects because I don’t want my child to be in this study or my
child does not want to be in this study.
Caregiver Consent
By signing my name below, I freely agree to allow my child to participate in this interview and for the
interview to be audio-recorded. I read this form or it has been read to me. I understand what it says. I
have been asked if I have any questions and my questions (if any) have been answered.
______ Please check here if you are willing to have the interview audiotaped.

I, ______________________________________, have read the above, or it has been read to me. My child
may participate. (Caregiver/Guardian)
Guardian’s Signature: _________________________

Date:

_________________

THANK YOU

Native Aspirations Evaluation

CMP Youth Interview – Caregiver Consent

9.4.2008

Evaluation of the Native Aspirations Project
Document B.12: Community Plan Evaluation Interview
Version 2 – Former Team Members
Youth Assent
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. Macro International Inc. is working with
SAMHSA on this project, and is holding interviews with attendees involved in Community Mobilization and
Planning (CMP) in order to help SAMHSA better understand the development, and implementation of
community plans.
Description of Participation
The interview will last about 20 minutes. We will a set of questions about the community mobilization
planning process; the community awareness about the project; and the impact of the Native Aspirations
Project on your community. You were asked to participate because you have been involved in developing
the community mobilization plan for the Native Aspirations Project in your community. If you decide to
join in the interview, here are some things you should know:
Payment
If you agree to participate in the 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 participate 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
you or others, which we will report to the appropriate local and state agency. Additionally, DHHS may see
Native Aspirations Evaluation

CMP Youth Focus Group – Youth Assent

9.4.2008

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.
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).
Rights Regarding Participation
I understand that I will not be in trouble if I do not want to be a part of this interview or if I decide to quit
after it has started. I do not have to answer questions that I do not want to answer. If I change my mind
and quit, all of my answers to questions will be destroyed, if that is what I want. No one will say that I
can’t be in other projects because I don’t want to be in this study.

Voluntary Assent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree to be in the
project.
______ Please check here if you are willing to have the interview audiotaped.

Print your name:

_________________________

Date:

__________________

Signature:

_________________________

Witness: __________________

THANK YOU

Native Aspirations Evaluation

CMP Youth Focus Group – Youth Assent

9.4.2008