Campus Staff Supporting Documents

Document I.4
OMB No. 0930-0286
Expiration Date: 05/31/10

Garrett Lee Smith Memorial (GLS) Campus Case Studies

Campus Case Study Focus Group – Faculty/Staff
CONSENT FORM
The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United
States Department of Health and Human Services is sponsoring case studies as part of the Garrett
Lee Smith Suicide Prevention Campus Program. Campuses across the United States and its
Territories have received grant awards to fund suicide prevention programs on campus. On
behalf of SAMHSA, Macro International Inc. is holding focus groups that will help SAMHSA
better understand the perspectives of faculty, staff, and students in regards to suicide prevention,
help-seeking, coping mechanisms, and risk/protective factors related to suicide prevention.
We are asking you to take part in a discussion about these issues. We are asking you to
participate in the focus group because you interact directly with students and may interact with
students who are at-risk for suicide. The focus group will take no more than an hour and a half of
your time. If you agree to be in the group, here are the things you should know:
-

You are free to join the study or not. You may choose to leave the group at any time for any
reason with no penalty or consequence.

-

You can choose not to answer any question at any time for any reason.

-

For the focus group, we will ask you to use only your first name or an alternate name. We
will give you a tag with your name on it. You can expect that study staff will sit in and take
notes during your focus group session.

-

The meeting will be audio taped. The tapes are to help learn more about what is said by all of
you as you discuss the topics. At the end of the study, we will erase the tapes and throw them
away.

-

Your name and answers to these questions will be kept private. To protect your privacy, we
will keep the records and tapes in locked files and only study staff will be allowed to use
them. Your name and other facts that might point to you will not appear when we present this
study or publish its results.

-

Project staff from Macro International Inc. will observe the group.

GLS Campus Case Studies

Faculty/Staff Informed Consent

1.23.2008

-

Your input in this focus group poses few, if any, risks to you. None of the questions asked
are of a sensitive nature, so none of them should make you uneasy. You can choose not to
answer any question for any reason.

-

The benefit of this group to you is that your input will help SAMHSA to build better
programs that will focus on suicide prevention and increase mental health seeking behaviors.

Contact information: If you have concerns about your rights in the study, contact Christine
Walrath at Macro International Inc., New York, NY at (212) 941-5555.
Please sign below to indicate that you have read the above and agree to take part in this focus
group.
Please print your name
Please sign your name
Witness signature
Date

THANK YOU

GLS Campus Case Studies

Faculty/Staff Informed Consent

1.23.2008

Document J.8
OMB No. 0930-0286
Expiration Date: 05/31/10
Garrett Lee Smith Memorial (GLS) Campus Case Studies

Campus Case Study Key Informant Interview
CONSENT FORM
The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States
Department of Health and Human Services is sponsoring case studies as part of the Garrett Lee
Smith Suicide Prevention Campus Program. Campuses across the United States and its Territories
have received grant awards to fund suicide prevention programs on campus. On behalf of
SAMHSA, Macro International Inc. is holding key informant interviews that will help SAMHSA
better understand the perspectives of administrators, faculty, staff, and students in regards to
suicide prevention, help-seeking, coping mechanisms, and risk/protective factors related to suicide
prevention. We are asking you to participate in a 45 to 60 minute face-to-face interview with a
trained interviewer who will ask you to respond to a set of questions about these important issues
and the culture of suicide prevention, mental health, and wellness on your campus. Here are some
things we want you to know about participating in the interview:
•

Participation in the interview is completely voluntary.

•

You may choose to discontinue the interview at any time, for any reason.

•

The meeting will be audio taped. The tapes are to help learn more about what is said by all of you
as you discuss the topics. At the end of the study, we will erase the tapes and throw them away.

•

Your name and answers to these questions will be kept private. To protect your privacy, we will keep
the records and tapes in locked files and only study staff will be allowed to use them. Your name and
other facts that might point to you will not appear when we present this study or publish its results.

•

There will be no direct benefit to you from participating in this evaluation. The benefit of this interview
to you is that your input will help SAMHSA to build better programs that will focus on suicide
prevention and increase mental health seeking behaviors.

•

Your input in this interview poses few, if any, risks to you. None of the questions asked are of a
sensitive nature, so none of them should make you uneasy. You can choose not to answer any question
for any reason.

•

A report that combines what we learn from all of the interviews conducted at your campus will be sent
to the suicide prevention staff at your campus. They may share that report with others at their
discretion.

•

Any questions you have about the evaluation will be answered before the interview begins.

GLS Campus Case Studies

Case Study Key Informant Consent

1.23.2008

•

Your signature below indicates that you understand the above and agree to participate.

Contact information: If you have concerns about your rights in the study, contact Christine
Walrath at Macro International Inc., New York, NY at (212) 941-5555.
Please sign below to indicate that you have read the above and agree to take part in this focus
group.
Please print your name
Please sign your name
Witness signature
Date

THANK YOU

GLS Campus Case Studies

Case Study Key Informant Consent

1.23.2008