Form I2. LAFI Consent t I2. LAFI Consent t I2. LAFI Consent to Contact Form

Training ID: 

OMB No. 0930-0286

Expiration Date: XXXX-XXXX

Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS) Campus Suicide Prevention Program

Life skills Activities Follow-up Interview (LAFI)

CONSENT-TO-CONTACT

As part of the Garrett Lee Smith (GLS) Youth Suicide Prevention and Early Intervention Cross-site Evaluation, we will be interviewing up to seven students who participated in the training activity you just completed. The purpose of the interview is to gain more in-depth information about the training experience you just completed, as well as to understand how you have used the skills and/or knowledge you obtained. Your participation in this brief interview is completely voluntary. Your answers to the survey questions will be kept private except as otherwise required by law. Your name will not be linked with the information on your survey. Your name will not be used in any reports about this evaluation.

We are interested in contacting you again within the next 3 months to ask you some questions about what you learned during this training and what impact it has had on you and your peers on campus. Findings from the interview will assist in informing the Substance Abuse and Mental Health Services Administration about suicide prevention activities and training experiences.

The interview will take approximately 20 to 30 minutes and will be conducted over the telephone by a member of the cross-site evaluation team. If you are selected to participate in the interview, you will be provided with $20 in appreciation of your time.

Are you interested in being contacted about possible participation in the Life skills Activities Follow-up Interview?

• Yes

• No

If you are interested in participating in this important effort, or in learning more about the Life skills Activities Follow-up Interview, please provide your contact information below. If you are selected to participate in the interview, a member of the cross-site evaluation team will contact you to schedule an interview. Participants for the interview will be randomly selected from a complete list of interested training participants.

Name:		Best Contact? (select yes or no)
Home Phone:		Yes No What’s the best time to call this Number?
CAMPUS Phone:		Yes No What’s the best time to call this Number?
Cell Phone:		Yes No What’s the best time to call THIS Number?
CAMPUS Address:
home Address:
Campus E-mail:
Personal E-mail:

If you have any concerns or questions about your participation in this study, please contact

Gingi Pica, ICF Macro at 212-941-5555.

Whether you selected yes or no above, please return this page to the training facilitator.
Thank you!

Life skills Activities Follow-Up Interview (LAI) Consent-to-Contact Form Page 0

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