Attachments A,C,D,E,F,G

Attachment A
Federal Wide Assurance

Office for Human Research Protections Database

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IRB Organization Information
IORG0000380 - Research Triangle Inst (RTI
International) (Active)
Located at: Research Triangle Park, NORTH CAROLINA
Expires: 01/31/2014

IRBs for this Organization: 3

Agency Only Access
IRB#

IRB Name City

State/Country

Status IRB Type

IRB00000653 Research
Triangle
Inst IRB
#1

Research
Triangle
Park

NORTH
CAROLINA

Active

OHRP/FDA

IRB00000654 Research
Triangle
Inst IRB
#2

Research
Triangle
Park

NORTH
CAROLINA

Active

OHRP/FDA

IRB00000655 Research
Triangle
Inst IRB
#3

Research
Triangle
Park

NORTH
CAROLINA

Active

OHRP/FDA

Department of Health and Human Services (DHHS) | Office for Human Research Protections (OHRP)

http://ohrp.cit.nih.gov/search/IOrgDtl.aspx

4/20/2011

Attachment C
Quality Control Form

VERSIÓN EN ESPAÑOL AL REVERSO
NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 2 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer,
Paperwork Reduction Project (0930-0110); Room 8-1099; 1 Choke Cherry Road, Rockville, MD 20857. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is 0930-0110.

OMB No.: 0930-0110
OMB Expiration Date:
01-31-XX

QUALITY CONTROL FORM
As part of our quality control program, we plan to contact a portion of the survey participants to
make sure that the interviewer has followed the study procedures. We only ask general
questions—no specific information is required. We sincerely appreciate your cooperation.
Please fill in the boxes below. (PLEASE PRINT CLEARLY.) Thank you.

[Your phone number will be kept confidential and will not be released to anyone other than our
quality control representatives.]
TELEPHONE
NUMBER

_

_
(Telephone Number)

(Area Code)
YOUR
ADDRESS
CITY

ZIP
CODE

STATE

BOXES BELOW MUST FIRST BE COMPLETED [IN INK] BY INTERVIEWER.
TODAY’S
DATE

M

M

_

D

D

_

1

FI
NAME
CASE
ID #

2

TIME

.
.

AM
PM

FI
ID #
_

_

_

Include
A or B!

IF respondent is 12 - 17 years old, which
adult granted permission for the interview? Æ
(Examples: father, mother, etc.)

[Print Parent/Guardian’s relationship to the child in this box.]

Attachment D
Lead Letter

DEPARTMENT OF HEALTH & HUMAN SERVICES

U.S. Public Health Service
Center for Behavioral Health Statistics and Quality
Rockville, MD 20857

______________, 2012

Dear Resident:
To better serve all people across the nation, the United States Public Health Service (USPHS)
is conducting a national study on health-related issues. Your address was randomly chosen
along with more than 200,000 others. Research Triangle Institute (RTI) is under contract to
carry out this study for the USPHS. Soon, an RTI interviewer will be in your neighborhood to
give you more information.
When the interviewer arrives, please ask to see his or her personal identification card. An
example of the ID card is shown below. The interviewer will ask you a few questions, and
then may ask one or two members of your household to complete an interview. It is possible
that no one from your household will be chosen to be interviewed. You may choose not to
take part in this study, but no one else can take your place. Every person who is chosen and
completes the interview will receive $30 in cash.
All the information collected is confidential and will be used only for statistical purposes.
This is assured by federal law. This letter is addressed to “Resident” because your address was
selected, and we do not know your name. Feel free to ask the interviewer any questions you
have about the study.
Your help is very important to this study’s success. Thank you for your cooperation.

Ilona S. Johnson
National Field Director, RTI
(800) 848-4079

pl
m
Ex
a

Joel Kennet, Ph.D.
National Study Director,
Center for Behavioral Health Statistics
and Quality

e

Sincerely,

______________________________
Assigned Field Interviewer

Confidentiality protected by the Confidential Information Protection and Statistical Efficiency Act of 2002 (PL 107-347)
Authorized by Section 505 of the Public Health Service Act (42 USC 290aa4)
Approved by Office of Management and Budget (OMB Approval No. 0930-0110)

Attachment E
Sorry I Missed You

Sorry I Missed You
Research Triangle Institute (RTI)
Research Triangle Park, NC 27709-2194

Sorry I Missed You
Research Triangle Institute (RTI)
Research Triangle Park, NC 27709-2194

Dear Resident:

Dear Resident:

I stopped by today to talk to you about an
important research study being conducted by
RTI.

I stopped by today to talk to you about an
important research study being conducted by
RTI.

I am sorry that I did not find you at home. I will
return to talk with you in the next few days.
Thank you in advance for your participation.

I am sorry that I did not find you at home. I will
return to talk with you in the next few days.
Thank you in advance for your participation.

Sincerely,____________________________________________

Sincerely,____________________________________________

Date: __________________________

Date: __________________________

Time: ______________

Time: ______________

Attachment F
Appointment Card

NSDUH Interview Appointment

NSDUH Interview Appointment

NSDUH Interview Appointment

NSDUH Interview Appointment

Interview Appointment

Interview Appointment

Just a reminder: I appreciate you taking time for this important study
and look forward to our appointment to complete the interview.
A $30 cash payment will be given to you upon completion of the survey!
I have you scheduled for the following:

Just a reminder: I appreciate you taking time for this important study
and look forward to our appointment to complete the interview.
A $30 cash payment will be given to you upon completion of the survey!
I have you scheduled for the following:

Day: ___________

Day: ___________

Date: _____________

Time: ____________

Field Interviewer: _________________________________________

Date: _____________

Time: ____________

Field Interviewer: _________________________________________

Research Triangle Institute
Research Triangle Park, NC 27709-2194

Research Triangle Institute
Research Triangle Park, NC 27709-2194

Interview Appointment

Interview Appointment

Just a reminder: I appreciate you taking time for this important study
and look forward to our appointment to complete the interview.
A $30 cash payment will be given to you upon completion of the survey!
I have you scheduled for the following:

Just a reminder: I appreciate you taking time for this important study
and look forward to our appointment to complete the interview.
A $30 cash payment will be given to you upon completion of the survey!
I have you scheduled for the following:

Day: ___________

Day: ___________

Date: _____________

Time: ____________

Field Interviewer: _________________________________________

Research Triangle Institute
Research Triangle Park, NC 27709-2194

Date: _____________

Time: ____________

Field Interviewer: _________________________________________

Research Triangle Institute
Research Triangle Park, NC 27709-2194

Attachment G
Study Description

Study
Description
U.S. Public Health Service
Center for Behavioral Health
Statistics and Quality
Your address is one of several in this area randomly chosen for the 2012 National
Survey on Drug Use and Health. This study, sponsored by the United States Public
Health Service, collects information for research and program planning by asking about:
• tobacco, alcohol, and drug use or non-use,
• knowledge and attitudes about drugs,
• mental health, and
• other health issues.
You cannot be identified through any information you give us. Your name and address
will never be connected to your answers. Also, federal law requires us to keep all of
your answers confidential. Any data that you provide will only be used by authorized
personnel for statistical purposes according to the Confidential Information Protection
and Statistical Efficiency Act of 2002.
The screening questions take just a few minutes. If anyone is chosen, the interview will
take about an hour. You can refuse to answer any questions, and you can quit at any
time. Each person who is chosen and completes the interview will receive $30
in cash.
If you have questions about the study, call the Project Representative at 1-800-8484079. If you have questions about your rights as a study participant, call RTI’s Office of
Research Protection at 1-866-214-2043 (a toll-free number). You can also visit our
project Website: http://nsduhweb.rti.org/ for more information.
Thank you for your cooperation and time.

Michael Jones, Project Officer
Center for Behavioral Health Statistics and Quality
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Public Health Service
Department of Health and Human Services
Your confidentiality is protected by the Confidential Information Protection and Statistical Efficiency Act of 2002
(CIPSEA, PL 107-347). Any project staff or authorized data user who violates CIPSEA may be subject to a jail
term of up to 5 years, a fine of up to $250,000, or both.