Supporting Documents for Mothers

A2-1

ATTACHMENT A-2:

SUPPORTING DOCUMENTS FOR MOTHERS

A.2.1

Consent Form

A.2.2

Informed Consent Form-Focus Groups

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Attachment A-2.1

Consent Form

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SAMPLE CONSENT FORM
I,

_______________________________________________, authorize

(NAME OF CONSUMER)

_________________________________________________________

(NAME OR GENERAL DESIGNATION OF PROGRAM MAKING DISCLOSURE)

to disclose to:
1.
2.
3. ____________________________________________________________________
(NAME OF PERSONS OR ORGANIZATIONS TO WHICH DISCLOSURE IS TO BE MADE)

the following information:
_____________________________________________________________________________
(NATURE OF THE INFORMATION, AS LIMITED AS POSSIBLE)

The purpose of the disclosure authorized herein is to:
______________________________________________________________________________
(PURPOSE OF DISCLOSURE, AS SPECIFIC AS POSSIBLE)

I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol
and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless
otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to
the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as
follows:
______________________________________________________________________________
(SPECIFICATION OF THE DATE, EVENT, OR CONDITION UPON WHICH THIS CONSENT EXPIRES)

______________________________________________________________________________________
(Date)
(Print Name)
(Signature of Consumer)

________________________________________________________________________
(Date)

(Print Name)

(Signature of Parent, Guardian or Authorized Representative when required)

The following notice must accompany a disclosure of information concerning a consumer in alcohol/drug abuse
treatment, made to grantee organization with the consent of such consumer. This notice is not to be altered in
anyway.
PROHIBITION ON REDISCLOSURE OF INFORMATION CONCERNING CONSUMER IN ALCOHOL OR DRUG
ABUSE TREATMENT STATEMENT
This information has been disclosed to you from records protected by Federal confidentiality rules (42
CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information
unless further disclosure is expressly permitted by the written consent of the person to whom it pertains
or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other
information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to
criminally investigate or prosecute any alcohol or drug abuse patient.

1

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Informed Consent for Data Collection
The purpose of your participation in this data collection activity is to collect information to assess the
effectiveness of treatment services received by you (and/or your children) here at
__________________________. You and/or your child’s participation is encouraged but
(Name of Treatment Agency)
completely voluntary. The expected duration of this data collection activity is approximately fourteen
months. You and/or your child have the right to stop participating in this data collection activity at any
time without discontinuing your treatment services for yourself or your child.
The risk in participating in this data collection is seen as minimal. However, because some questions
are of a sensitive nature, you or your child may feel uncomfortable. To minimize this risk, precautions
have been taken to select questions that are frequently asked in Substance Abuse treatment programs.
In the event you or your child becomes uncomfortable answering any of these questions, there will be
clinically trained staff to provide any necessary support services.
If you have any questions regarding this data collection activity, please contact
_______________________________________________________________________
Name/Title/Address/Phone Number
By signing below, I am voluntarily agreeing to have myself and or my child participate in this data
collection activity.
________________________________________________________________________
Name (Print Name)

Signature of Child

Date

________________________________________________________________________
Name (Print Name)

Signature of Parent, Guardian or Authorized Rep. when required Date

____________________________
Signature of project staff/witness

______________

Date

This form is valid until ___________________________. (Insert Date)

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Attachment A-2.2

Informed Consent Form-Focus Groups

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INFORMED CONSENT FORM
Title: Evaluation of Pregnant and Postpartum Women (PPW)
Study Description: Westat, (a private research company), is conducting a cross-site evaluation
of PPW programs on behalf of the Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment (CSAT). The purpose of this study is to
evaluate the effectiveness of PPW programs that received Federal funds and obtain information
about how they can be improved. As part of this study, Westat is conducting site visits to PPW
programs and focus groups with PPW clients. You are being asked to participate in this focus
group because of your participation in this PPW program. This focus group will last about one
to one and a half hours.
Risks and Benefits: There are no known risks for participating in this focus group. If you feel
uncomfortable with any of the questions being asked you do not have to respond and may leave
the focus group at any point. There is no direct benefit to you in participating in this focus
group; however, your responses along with the responses from others will be used to inform
future PPW programs and improve existing PPW programs.
Privacy: All information provided during this focus group will be kept private. However, if
threats to your safety (e.g., suicidal thoughts) or the safety of others (e.g., child abuse and/or
neglect, homicidal thoughts) are mentioned during the focus group discussion, we will report this
information to PPW program staff.
During the focus group, only your first names will be used. Your responses will be combined
with information provided by other clients (including clients in other PPW programs funded by
CSAT) and reported in aggregate form. To ensure your privacy, we will not link an individual’s
name with a specific response when reporting our results. The audiotape recording of this focus
group will be kept in locked file cabinets and no names will be used when creating the transcript
of this focus group.
Right to Withdraw: You may refuse to participate in this focus group and you may stop
participating at any time. You also do not have to answer any questions that you do not want to
answer.
Voluntary Consent: Your signature below indicates that you have read the information
provided above and have decided to participate. Your signature also indicates that you have
given permission to be audiotape recorded during the focus group. You can keep a copy of this
form.
Any questions that you may have about this study may be answered by Wendy Kissin, Ph.D.
(Project Director) 301-294-3885; and any questions about your rights as a research participant
may be answered by the IRB Administrator of the IRB Office, Westat (301-610-8828).
____________________________________
Participant’s Signature

_____________________
Date