Service_Provider_Supporting

Attachment 8 – Service Provider Supporting Documents
Document D.3: Service Provider Focus Group Version 1 Consent
Document D.4: Service Provider Focus Group Version 2 Consent

Evaluation of the Native Aspirations Project
Document D.3: Service Provider Focus Group – Clinical/Agency Staff
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 focus groups that will help SAMHSA better understand provider and service
availability for Native youth, and the perspectives of providers in regards to the impact of the Native
Aspirations program on services and service delivery.
Description of Participation
We are asking you to take part in a discussion about the availability of wellness and mental health
services, how agencies work together, awareness of violence/suicide prevention activities, and areas for
improvement in your community. We are asking you to participate in the focus group because you are a
provider of youth services in your community. The focus group will last approximately 2 hours. You
may be asked to participate in up to two focus groups; one in year 1 (baseline) and one in year 3 (follow
up) of the grant. If you agree to be in the group, here are the things you should know:
Risk & Benefits
Your input in this focus group poses few, if any, risks to you. None of the questions asked are of a
sensitive nature, so none of them should make you uneasy. 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 for participating in the focus
group now and $20 to participate in the focus group two years from now.
Confidentiality
All responses will be treated confidentially. We will be taking notes during the discussion group about
what was said, but we will not link responses to your identity. The discussion 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
Native Aspirations Evaluation

Service Provider Focus Group Consent_v1 Agency Staff

9.4.2008

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
You are free to join the study or not. You may choose to leave the group at any time for any reason with
no penalty or consequence. You can choose not to answer any question at any time for any reason. If
you change your mind and quit at any time, 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 focus 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).
______ Please check here if you are willing to have the discussion audiotaped.

Please sign below to indicate that you have read the above and agree to take part in this focus group.
Please print your name
Please sign your name
Date
THANK YOU

Native Aspirations Evaluation

Service Provider Focus Group Consent_v1 Agency Staff

9.4.2008

Evaluation of the Native Aspirations Project
Document D.4: Service Provider Focus Group – Non-Agency Staff
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 focus groups that will help SAMHSA better understand provider and service
availability for Native youth, and the perspectives of providers in regards to the impact of the Native
Aspirations program on services and service delivery.
Description of Participation
We are asking you to take part in a discussion about the availability of wellness and mental health
services, how agencies work together, awareness of violence/suicide prevention activities, and areas for
improvement in your community. We are asking you to participate in the focus group because you are a
provider of youth services in your community. The focus group will last approximately 2-hours. If you
agree to be in the group, here are the things you should know:
Risk & Benefits
Your input in this focus group poses few, if any, risks to you. None of the questions asked are of a
sensitive nature, so none of them should make you uneasy. 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 for participating in the focus
group now and $20 to participate in the focus group two years from now.
Confidentiality
All responses will be treated confidentially. We will be taking notes during the discussion group about
what was said, but we will not link responses to your identity. The dicussion 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.

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
Native Aspirations Evaluation

Service Provider Focus Group Consent_v2 Non- Agency Staff

9.4.2008

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
You are free to join the study or not. You may choose to leave the group at any time for any reason with
no penalty or consequence. You can choose not to answer any question at any time for any reason. If
you change your mind and quit at any time, 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 focus 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).
______ Please check here if you are willing to have the discussion audiotaped.

Please sign below to indicate that you have read the above and agree to take part in this focus group.
Please print your name
Please sign your name
Date
THANK YOU

Native Aspirations Evaluation

Service Provider Focus Group Consent_v2 Non- Agency Staff

9.4.2008