Stakeholder Survey Consent Form

Attachment 7: CSAT GBHI Stakeholder Survey Consent Form

OMB No. 0930-xxxx

Expiration Date xx/xx/xx

RTI IRB Approval No. 12612

Consent to Participate in an Evaluation Study

Center for Substance Abuse Treatment (CSAT) Grants to Benefit Homeless Individuals (GBHI) Program Cross-Site Evaluation

Stakeholder Survey Consent

[Appears right after use of Password to login to site, before Intro to survey

Respondent must click “Accept” before survey modules appear]

About the Study

This survey is part of a national evaluation effort to describe the implementation, effectiveness and sustainability of the Center for Substance Abuse Treatment’s (CSAT) Grants to Benefit Homeless Individuals (GBHI) Treatment for Homeless programs throughout the country. The evaluation will examine the effects of the CSAT GBHI project activities on client outcomes, treatment services, treatment systems and cost, and identify challenges and successes in implementing and sustaining a program for homeless individuals who have substance abuse and mental health problems. RTI International is conducting the cross-site evaluation for the Substance Abuse Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment. You were nominated by the CSAT GBHI grantee as someone knowledgeable about the CSAT GBHI project in your community. Your perspectives on your local CSAT GBHI project and services are vital in helping CSAT to improve GBHI and the supports it offers to clients.

The following questions ask about your experiences as a stakeholder partner to a current local CSAT GBHI project, [Program Name], that was implemented in [county] by [agency name] on [date]. These questions are designed to gather background information about your agency, the services provided, and your experience partnering on the implementation and sustainability efforts of the local CSAT GBHI program.

Voluntary Participation and Privacy

Your decision to take part in this evaluation study and your participation is completely voluntary. You can refuse any part of the study and you can stop participating at any time. You can refuse to answer any question.

All the information you provide in this survey will be kept private and will not be shared with anyone from your agency. RTI will not be documenting your name and will not be able to connect your survey responses to your name. At no time will your employer or anyone else not connected with the research see your responses. If the results of this study are presented at scientific meetings or published in scientific journals, no information will be included that could identify you or your answers personally or directly identify your agency.

Risks and Benefits of the Study

There are no known risks of participation in this online web survey. It will take about 17 minutes of your time including review of this consent. There are also no immediate benefits of participation. No incentive for participation is provided. Information from key stakeholders like you will be aggregated and the results will help stakeholders, practitioners, policy makers, researchers and funders learn more about the efforts of local CSAT GBHI Initiatives and factors contributing to their success.

Questions

You are welcome to contact our office any time if you have questions about the survey. Please call Dr. Nahama Broner at 1-877-353-3422, leave a message and she will return your call. You can also email Dr. Broner at [email protected] or write to her at RTI International, 121 West 27^th Street, Suite 1001, New York, NY 10001.

If you have any questions about your rights as a research study participant, you may call the RTI International Office of Human Subject Protections toll-free at 1-866-214-2043; or you can write to them at RTI International Office of Human Subject Protections, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, North Carolina, 27709-2194.

By clicking on the tab below, you agree to participate in the study. Please check the box only if:

• You understand the information about the study in this consent form, and

• You are willing to continue to participate in the study.