Form CallerI Initial Sc CallerI Initial Sc CallerI Initial Script

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OMB No. 0930-0274
Expiration Date: XX/XX/2016
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 0930-0274. Public reporting burden for this collection of
information is estimated to average 5 minutes per client 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.

MI/SP Caller Initial Script
Telephone Script for Obtaining Client’s Approval for Research Re-contact
“Before we hang up, I’d like to describe a telephone research survey that is being conducted with people
who receive follow-up from a crisis line. The reason for doing the interview is to find out how people are
doing in the weeks after we talked to them and to see if crisis centers are providing effective services to
their clients. Our center is working with researchers at Columbia University to do this telephone
assessment. For purposes of consent, the study has to be limited to people who are 18 years of age or
older.”
1) Are you 18 years of age or older?

 Yes (18 years or older)

 No (younger than 18 years)

IF CLIENT IS YOUNGER THAN 18 YEARS OF AGE, PLEASE DO NOT REQUEST PERMISSION FOR RE-CONTACT

“Right now, we would just like to find out whether it is okay for the research/evaluation team from Columbia
University to call you to tell you more about the study. They would be calling you about 6 weeks past the
time you were referred to us for follow-up. Do you think it would be okay for someone from Columbia
University to call you to see if you might be interested in participating in the telephone research survey?
Only some clients will be re-contacted for the survey. The selection of the clients will be random (like
flipping a coin) and has nothing to do with you personally. If they call you they will give you all the details
about the research. While they need your name to call you back, your name will not be connected to any of
your answers on the survey or any reports that come out of the evaluation project. The survey will take
about 30 to 40 minutes and you will be paid $50 for helping with this evaluation.”
PLEASE FILL IN BLANKS AND CHECK APPROPRIATE BOXES:

2) Client’s Gender:

 Male

3) Client’s Age: ___________

 Female

 Unknown

 Unknown

4) Date of Client’s Referral for Follow-up: _____/_____/_____ (mm/dd/yy)
5) Client was referred for follow-up subsequent to: (please choose one)
 Suicidal hotline call

 ED discharge

 Inpatient discharge

6) For hotline callers only: Line called:  Lifeline (NSPL)

 Other: ________________

 Local/other line

7) Date of Follow-up Call during which request was made: _____/_____/_____ (mm/dd/yy)
8)  Client Agreed

 Client Refused

9) ____________________________________
Signature of Person Asking for/Obtaining Approval

________________________________________
Printed Name of Person Asking for/Obtaining Approval

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ONLY PROVIDE NAME AND REMAINING INFORMATION BELOW IF CLIENT HAS AGREED:
10) Client’s Name: ____________________________________________________________________
Contact Details for Columbia’s Call:
11) Telephone number for Columbia’s call: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
12) Best days & times to call: ____________________________________________________________
13) "The telephone number you gave me, is it for a cell phone?"

 Yes

 No

14) Alternate telephone number for Columbia’s call: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
15) Best days & times to call: __________________________________________________________
16) Caller ID?

 Yes

 No

(If "No," skip to question 17.)

IF YES: 16a) “Should they block their identity when they call you?”
17) Do you have voicemail or an answering machine?

 Yes

 No

 Yes

 No

(If "No," skip to question 18.)

IF YES:
17a) If you're not at home when Columbia University calls, is it okay for them to leave a message on
your answering machine? They could say, "This is Columbia University calling to see if you'd
be interested in participating in a telephone survey," or they could leave a different message.
 Do Not Leave Message
 Leave Columbia Message
 Leave Different Message: (If "Yes," write down exact message to be left:)
_________________________________________________________________
_________________________________________________________________
18) If someone else answers when Columbia University calls, is it okay for them to leave a message with
the person who answers the phone? If you wanted them to leave a message, they could say, "This is
Columbia University calling to see if you'd be interested in participating in a telephone survey," or they
could leave a different message.
 Do Not Leave Message
 Leave Columbia Message
 Leave Different Message: (If "Yes," write down exact message to be left:)
______________________________________________________________________
______________________________________________________________________

PLEASE CHECK that you have answered
Questions 1-9 for callers who have REFUSED re-contact permission, and
Questions 1-18 for callers who have GIVEN re-contact permission.

THANK YOU!
WE VERY MUCH APPRECIATE YOUR COLLABORATION ON THIS PROJECT.