Consent Form

Attachment C

Release and Consent Form

OMB No. 0930-0196

Expiration Date: 09/30/16

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 0930-0196.  Public reporting burden for this collection of information is estimated to average 90 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.

RELEASE AND CONSENT FORM

Consent Form: Focus Groups

Purpose:

The Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is conducting an assessment of their campaign to reduce underage drinking called “Talk. They Hear You.” This focus group is being conducted on SAMHSA’s behalf by Synergy Enterprises, Inc. The purpose of the study is to examine the impact of the campaign materials. Specifically, we want to understand what information parents and caregivers remember and use after seeing the ads, posters, and website for “Talk. They Hear You.” We will use this information to evaluate how well the campaign is reaching its audience.

Procedures:

If you participate in this study, you will be in a group of approximately 8 other parents/caregivers of children ages 9–15. There will be a facilitator who will ask questions and facilitate the discussion, and a note taker to write down the ideas expressed within the group. We will also be recording the session to help clarify the information written down by the note takers, should there be any questions in summarizing the results. If you volunteer to participate in this focus group, you will be asked some questions relating to your knowledge, attitudes, and skills with regard to preventing underage drinking and whether you have used this information in talking to your own children. We will not be asking specific information about your alcohol use or your children’s use. No personal information will be included in the notes; we are using first names only during the session.

Your participation is completely voluntary. You may withdraw from this study at any time without penalty. The estimated time for completing this focus group is 90 minutes.

Benefits and Risks:

Your participation may benefit you and other parents and caregivers of children by helping SAMHSA to improve the information they distribute to help reduce underage drinking. No risk greater than those experienced in ordinary conversation are anticipated. Everyone will be asked to respect the privacy of the other group members. All participants will be asked not to disclose anything said within the context of the discussion, but it is important to understand that other people in the group with you may not keep all information private and confidential.

Privacy:

Anonymous data from this study will be analyzed by Synergy Enterprise, Inc. staff and reported to SAMHSA. No individual participant will be identified or linked to the results. Study records, including this consent form signed by you, may be inspected by SAMHSA or the Office of Management and Budget which oversees all research conducted on behalf of government funded agencies. The results of this study may be presented in reports to SAMHSA and other government agencies or Congress; however, your identity will not be disclosed. All information obtained in this study will be protected. All materials will be stored in a secure location by Synergy Enterprises, Inc. and access to files will be restricted to paid professional staff.

Consent:

By signing below, you are indicating that you fully understand the above information and agree to participate in this focus group.

Participant's signature: ___________________________________________

Printed name: ________________________________________

Date: _____________________________________________

If you have any questions or concerns about this study, please contact [insert responsible party and contact information].

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