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 30 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
Life skills Activities (LAFI) Follow-up
Verbal Consent Script and Interview Guide
Date: (Today’s Date) / /
Site: (Name of Grantee) ____________________
Participant ID:
Interviewer: _________________________
Verbal consent provided:
Yes
No
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 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.
I'm contacting you because you were randomly selected to participate in these interviews. We are conducting up to seven interviews with a small sample of trainees from the training you participated in, as well as with people who have participated in other suicide prevention trainings as part of these SAMHSA-funded programs across the nation. This is why your input is so important.
The interview will take no more than 20 or 30 minutes, and you will receive $20 money order for participating. 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 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 survey poses few, if any, risks to you. Some questions may make you feel uncomfortable. You may choose to stop the survey at any time. You may choose to not answer a question for any reason. You can choose not to answer any question for any reason. There is no penalty or consequence to you. You also can contact the evaluation project director 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.
I will be taking notes during the interview, but I would like to get your permission to record this interview in order to make sure we have an accurate transcript of the information you give us. If you agree to be recorded, your recording will be kept in a private file that only ICF staff has access to and it will be destroyed upon the completion of the evaluation. If you do not wish to be recorded, I will refrain from recording the interview.
Compensation: You will receive $20 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.
Do I have your permission to record this interview?
IF YES, continue to Part I–Background Information.
Life
skills Activities Follow-up Interview (LAFI) Page
09.23.2013
| File Type | application/msword |
| File Modified | 2014-01-03 |
| File Created | 2014-01-03 |