Client Interview Consent

Attachment 6: CSAT GBHI Client Interview 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 for the Benefit of Homeless Individuals (GBHI) Program Cross-Site Evaluation

Client Interview Consent

Introduction

You are being asked to take part in a national study of the Center for Substance Abuse Treatment (CSAT) Grants for the Benefit of Homeless Individuals (GBHI) Program. The study is going to measure how the program is doing in helping people who have been homeless. This form describes who can be in the study and the risks and benefits of being in the study. This form also tells how your information will be protected and who you can call if you have any questions. Please ask the interviewer to explain anything you don’t understand before you make your decision.

Purpose

RTI International (RTI) is an independent non-profit research company in Research Triangle Park, North Carolina. RTI is conducting this study of the CSAT GBHI Program. The questions in this survey are asked as part of this study. The survey is meant to help us learn how the program is doing. It may also help find ways to make the program better. This survey is sponsored by a government agency called the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) CSAT. RTI is working with the [Grantee’s GBHI Program] to administer this survey. Because you are a client of the CSAT GBHI Program, we are asking for your help in this important survey.

Procedures

This survey has two parts. The first part asks questions about your experiences, needs and the services you have received, as well as your background and attitudes toward drugs and alcohol. These questions will be read to you by the GPRA interviewer from the program. The second part asks about your satisfaction with the CSAT GBHI Program. You will have the opportunity to fill out these questions on your own so that your opinion of the program can remain private. Please place your answers in the provided envelope. Once you have sealed the envelope, please give it to the interviewer. If you choose to take part in this survey, you will be asked to complete it again when you come to complete your 6-month GPRA interview.

Study Duration

Completing the survey takes about [at baseline: 20 minutes] [at 6-month: 24 minutes]. That includes time for reading the instructions and answering the survey questions, as well as completing the satisfaction questions.

Risks and Benefits

There is a small risk that answering the questions may make you feel uncomfortable or sad. If this happens, the GPRA interviewer can connect you with someone from your program who can help. The information collected in this survey will help us learn how the CSAT GBHI Program is doing. It may also help improve the program for future clients. The survey allows CSAT GBHI clients like you a chance to give their thoughts on the CSAT GBHI Program.

Privacy

RTI will not be given your name or any other personal identifying information. The program will assign an ID number to protect the privacy of your responses. RTI will not be able to connect your survey answers to you. Your survey answers will be combined with other answers from people in the [Grantee’s GBHI Program] and across the country.

Your Rights

This survey is voluntary. That means you can refuse to answer any question. It also means you can choose not to take part in the survey at all. Answering this survey will not affect any parole status, probation status, or other legal status you may have. Answering this survey will also not affect your ability to receive any of the services you are receiving from your program including treatment and housing. If you participate in the baseline survey you do not have to participate in the 6-month follow-up survey.

Incentive

To thank you for taking the time to give us your feedback, we will give you a non-cash coupon worth $10.00 today; you will also receive a non-cash coupon worth $25.00 at the 6 month follow-up interview if you decide to participate in the survey at that time.

Your Questions

If you have questions about this study, please call Dr. Nahama Broner, the study’s principal investigator, toll-free at 1-877-353-3422, leave a message and she will return your call. You can also email the evaluation at [email protected]. If you have questions about your rights in this study, please call RTI's Office of Research Protection 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.

Your signature below indicates that you have read (or been read) the information provided above, have received answers to your questions, and have freely decided to participate. By agreeing to participate in this evaluation, you are not giving up any of your legal rights.

Date		Signature or Mark of Participant
		Printed Name of Participant

I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this evaluation have been explained to the above-named individual.

Date		Signature of Person Obtaining Consent
		Printed Name of Person Obtaining Consent