OMB No. 0930-0286
Expiration Date: XXXX-XXXX
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 0930-0286. Public reporting burden for this collection of information is estimated to average 10 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.
Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS) Campus Suicide Prevention Program
Training Utilization and Preservation–Survey
Campus Version
Verbal Consent
Hello, my name is [INSERT INTERVIEWER NAME], and I'm calling to talk to you about the training that you attended on [INSERT TRAINING DATE]. Is now a good time for me to give you more information?
IF NO: Is there a better time to call back?
IF YES: Great! As I said, my name is [INSERT INTERVIEWER NAME], and I work for ICF, a company that has been contracted to conduct a cross-site evaluation of suicide prevention programs funded by SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration). As part of this evaluation, we are interviewing a random sample of people who have attended a campus suicide prevention trainings. We hope to learn more about the trainings, how you have used what you learned, and the impact of the training on you and your interactions with your peers.
On [DATE OF TRAINING] you participated in a training called [INSERT TRAINING NAME], as part of the Garrett Lee Smith Memorial (GLS) Campus Suicide Prevention Program. At the end of the training, you consented to be contacted for a follow-up survey. We are contacting you now to administer the survey. This survey asks questions about the training, what you plan to do with what you learned during the training, and your satisfaction with the training. Findings from this survey will help inform SAMHSA about suicide prevention activities.
All participants in training activities funded as part of your Campus youth suicide prevention program are being asked to complete this survey. Therefore, your participation is very important. The survey questions will ask you about your participation in [INSERT TRAINING NAME].
The survey will take approximately 10 minutes to complete and you will receive $10 for your participation. If you are interested, I will give you some more information and get your verbal consent.
Before I ask you whether you agree to be interviewed, there are a few more things that you should know:
Rights Regarding Participation: Your input is important; however, your participation in this survey is completely voluntary. There are no penalties or consequences for not participating. You can choose to stop the interview at any time, or not answer a question, for whatever reason. If you stop the interview, at your request, we will destroy the survey. You may ask any questions that you have before, during, or after you complete the survey. May I continue?
Privacy: Your answers are private and will not be linked to your name. Your name will never appear in any report that summarizes the findings of the cross-site evaluation. All findings will be reported in aggregate; this is, they will be combined with responses from other individuals.
Additional Protection: In addition, to protect the information that you give us, we have applied for a Certificate of Confidentiality from the United States Department of Health and Human Services (DHHS). The Certificate of Confidentiality will protect the members of the research staff from being forced, even under a subpoena, to release any information in which you are identified. Exceptions to the Certificate of Confidentiality are information on child abuse and neglect, or information regarding imminent danger to yourself or others, which we will report to the appropriate local and state agency. Additionally, DHHS may see your information if we are audited. Finally, the certificate of confidentiality does not imply the endorsement or the disapproval of the DHHS.
Risks: Completing this interview poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a question, for whatever reason. You will not be penalized for stopping. You can contact the evaluation team lead in charge of this survey at any time. If you stop the interview, at your request, we will destroy your survey.
Benefits: Your participation will not result in any direct benefits to you. However, your input will contribute to a national effort to prevent suicide on college campuses.
I am not an expert in the subject matter, and I do not work for the people who provided the training, so you can't hurt my feelings and there aren't any wrong answers. We're just interested in your thoughts and opinions.
Compensation: You will receive $10 for participating in this survey.
Contact information: If you have any concerns about completing this survey or have any questions about the study, please contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].
Do you have any questions?
Do you agree to participate in this interview?
IF YES, continue.
Thank you in advance for your willingness to participate. This call may be recorded and/or monitored for quality assurance purposes.
Training
Utilization and Preservation–Survey: Campus Version Page
09.23.2013
| File Type | application/msword |
| File Modified | 2014-01-03 |
| File Created | 2014-01-03 |