H Example of an Informed Consent Form 12.27.12

OMB No. 0930-0277
Expiration Date: XX/XX/XXXX

CONNECTICUT DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
HARTFORD WOMEN’S TRAUMA AND SUPPORT DIVERSION PROGRAM
INFORMED CONSENT
Invitation to Participate and Description of Project: You are being invited to take part in a research
study of a federally funded program serving women in the criminal justice system. We are asking you
because you are in the programs we are studying, [program name:] ___________________________.
You do not have to be part of the study to stay in this program, or to get any other services you may be
getting for mental health, substance abuse, or housing. We want to make sure you understand that
agreeing to be part of the study does not affect your legal situation in any way; it does not help you,
and it does not hurt you. Before agreeing to be part of this study, please read and/or listen to the
following information carefully and feel free to ask your case manager, treatment staff, or the
interviewer any questions you might have.
Description of Procedures: If you decide to be in this study, you will be asked to participate in three
research interviews. The first one is today, and the others are six and twelve months from now. These
interviews will last about 45 minutes. The interviews will include questions about you and your family
and your current and past housing, past problems you may have had, and how your life is going in
terms of living situation, health, activities, mental health, substance use, and treatment. The interviews
will take place in a location convenient to you, in court, at a treatment facility, other program, your
home, or elsewhere. Also, we will ask you for permission to get information from court, from
correction, and from the Department of Mental Health and Addiction Services, but we will not talk to
them unless you sign a separate form.
If you are in jail during the year that you are in the study, we will ask you to sign another
consent form. At this time you can let us know if you want to be interviewed while you are in jail.
The interviews will take place in meeting areas at the jail set aside for professional visitors.
Risks and Inconveniences: There is a possibility that some of the questions in the interviews may
make you feel uncomfortable. If this happens, we can do any of the following: You can choose not to
answer certain questions. You can take a break and continue later. You can choose to stop the
interview. If you wish, we can call your clinician, another staff member or concerned others to make
sure you have someone to talk with about your feelings. However, when people are in jail, mental
health services are not always immediately available.
There is also a small possibility that staff may reveal information to someone who should not have it.
However, the staff are carefully trained not to do this, and all staff members are told that they will be
fired from their jobs if they ever reveal information that they are not supposed to reveal.
Benefits: This study is not being done to help you, personally. You should know that being in this
study will not help you with any criminal charges you may have or with your legal status. What we
learn from you may help others in the future by making services and programs better.
Public Burden Statement: 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 0930-0277. Public reporting
burden for this collection of information is estimated to average 50 minutes per respondent, per year, 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, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Confidentiality: The research team will keep any information you give us confidential, and we will
not share it with anyone outside of the research team, with certain exceptions. To help keep
information about you private and confidential, we have a Confidentiality Certificate from the federal
agency giving us money for the study, the Department of Health and Human Services (DHHS). This
Certificate does not imply that the Secretary of DHHS approves or disapproves of the project. This
Certificate will protect the researchers from being forced to give information about you to others, even
under a court order or subpoena. Even with a Confidentiality Certificate, however, there are some
times we have to give other people your information. We may report it if we believe that a child or
elderly person is at risk of being harmed. Also, if you tell us you are going to physically hurt yourself
or someone else, we may contact someone who can help. There is also a possibility that the agency
giving us money for this study (DHHS) will want to do an audit, that is, check to see if we are using
the grant money the right way. If they do an audit, we have to let them see any files they need,
including files that contain your information. Also, you can give permission to let people know that
you are in the study.
Voluntary Participation: Your participation in this study is entirely voluntary. Refusal to participate
in any part of the study will not affect the services that you are receiving now or in the future. You can
stop being in the study at any time without affecting your treatment or other services. Also, if you
refuse, it will not make any difference in your court case, or your privileges in jail, if you should go to
jail. It will also not help you to get out of jail sooner.
Questions: Please feel free to ask any questions about anything that seems unclear to you and to
consider this research and consent form carefully before you sign.
AUTHORIZATION
Please read the following statement: I have read or listened to the information on this consent form,
and I understand what is being asked of me. I understand that I will be asked to talk about things like
mental health, housing, substance use, and past trauma. I further understand that if I refuse to grant
consent, or if I decide to drop out, I still have the same rights to services as I always had.
I have decided that I will be in this project. My signature below also indicates that I have received a
copy of this consent form.
Signature of participant
Name (please print)

Date

Signature of Conservator, if applicable_________________________________________
Name (please print)

Date_______________

Signature of person obtaining consent
Name (please print)

Date

You can ask questions of Research Division staff about this project at any time. You can also contact
Linda Frisman, Ph.D., the head of this project, at any time to ask questions about the research or if you
have a complaint about the study. Her phone number at the Connecticut Department of Mental Health
and Addiction Services is 860-418-6788. You may also contact Karen A. Kangas, Director of Patients
Rights, Connecticut Department of Mental Health and Addiction Services at 1-800-446-7348, if you
feel that you have been treated unfairly in any way relating to this study or have any complaints or
questions regarding your rights as a participant in this study.