EBP Web Consent

Attachment 8: Evidence-Based Practice (EBP) Self-Assessment Web-based Consent

OMB No. 0930-XXXX

Expiration Date XX/XX/XXX

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-xxxx.  Public reporting burden for this collection of information is estimated to average 35 minutes to 1 hour 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 7-1044, Rockville, Maryland, 20857.

Consent to Participate in an Evaluation Study

Substance Abuse and Mental Health Services Administration (SAMHSA)

National Evaluation of SAMHSA’s Homeless Programs

Evidence-Based Practice Self-Assessment Web Survey Consent

[Appears right after use of Password to login to site, before Intro to survey

Respondent must click “Accept” before survey modules appear]

About the Study

This survey is part of a national evaluation effort to describe the implementation, effectiveness and sustainability of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services (CMHS) and Center for Substance Abuse Treatment (CSAT) Homeless Programs throughout the country. SAMHSA’s Homeless Programs include CSAT Grants for the Benefit of Homeless Individuals General (GBHI), Services in Supportive Housing (SSH) and Cooperative Agreements to Benefit Homeless Individuals (CABHI) grants, CMHS SSH and CMHS Projects for Assistance in Transition from Homelessness (PATH). The evaluation will examine the effects of the SAMHSA Homeless Programs project activities on client outcomes, treatment services, service systems and cost and identify challenges and successes in implementing and sustaining a program for homeless or housed individuals who have substance abuse and mental health problems. RTI International, an independent non-profit research company in Research Triangle Park, North Carolina, is conducting the national cross-program evaluation for SAMHSA’s Homeless Programs.

You were selected to participate as a grantee or partner implementing a SAMHSA Homeless Programs project funded in 2009, 2010, 2011, or 2012 under the SSH, GBHI, GBHI-CABHI or PATH initiative and as someone knowledgeable about the SAMHSA Homeless Programs project services. Your perspectives on your local SAMHSA (SSH, GBHI, GBHI-CABHI or PATH) project and services implementation are vital in helping SAMHSA improve its Homeless Programs initiatives and the supports your project offers to clients.

The following questions ask about your experiences implementing the services of your current local SAMHSA Homeless Programs project, [Project Name], that was implemented in [county] by [agency name] on [date]. These questions are divided into two parts. The first part of the survey asks about the key components of implementing evidence-based practices (EBP), including questions about training and factors that may serve as barriers or facilitators to implementation to fidelity within grantee projects, such as readiness to implement the EBP, leadership, funding, training and supervision, quality improvement, and outcomes. Some of the questions are focused on the grantee agency and/or the overall grant project, and others are focused on the provider implementing an EBP that is incorporated into your project, which may or may not be different from the grantee agency. The second part of the survey is completed only if your local project is implementing one or more of the following EBPs: Assertive Community Treatment (ACT), Integrated Dual Disorders Treatment (IDDT), Illness Management and Recovery (IMR), Supported Employment (SE) or Critical Time Intervention (CTI).

Voluntary Participation and Privacy

Your decision to take part in this evaluation study and your participation is completely voluntary. You can refuse any part of the study and you can stop participating at any time. You can refuse to answer any question.

All the information you provide in this survey will be kept private and will not be shared with anyone from your agency or directly with SAMHSA. RTI will assign you and your site each an ID number so that your name and the name of the local Homeless Programs project will not be included with your survey responses. Your name and your agency’s name and ID number will be kept separately from your responses in a password protected file on a computer encrypted with Point Sec and accessible only to the Project Director and Project Manager. Data provided via the Web survey is automatically downloaded after each question into a secure encrypted electronic database housed on a computer server located at RTI. RTI’s systems for collecting, storing, and processing data are designed to maintain the privacy of study participants and minimize the disclosure of information.

At no time will your employer or SAMHSA or anyone else not connected with the research team see your responses. When the results of this study are included in reports and presented at scientific meetings or published in scientific journals, no information will be included that could identify you or your answers personally.

Risks and Benefits of the Study

There are minimal risks of participation in this online web survey. As described above under privacy protections, we will reduce the risk of inadvertent disclosure by associating your responses with a unique identifier and not your name. To complete both Part 1 and Part 2 of this survey will take about 1 hour of your time including review of this consent; if your project is not implementing one of the five EBPs included in Part 2, completion of Part 1 will only take approximately 35 minutes, including review of this consent. There are also no immediate benefits of participation. No incentive for participation is provided. Information from Homeless Programs project and partner staff like you will be aggregated in all reports, presentations and publications and the findings may help stakeholders, practitioners, policy makers, researchers and funders learn more about the efforts of local SAMHSA Homeless Programs Initiatives and factors contributing to their success.

Questions

You are welcome to contact our office any time if you have questions about the survey. Please call Dr. Nahama Broner, the Project Director of the National Cross-Program Evaluation of SAMHSA’s Homeless Programs, toll-free at 1-877-353-3422, leave a message and she will return your call. You can also email Dr. Broner at [email protected] or write to her at RTI International, 121 West 27^th Street, Suite 1001, New York, NY 10001.

If you have any questions about your rights as a research study participant, you may call the RTI International Office of Research Protection toll-free at 1-866-214-2043; or you can write to them at RTI International Office of Research Protection, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, North Carolina, 27709-2194.

By clicking on the tab below, you agree to participate in the study. Please check the box only if:

• You understand the information about the study in this consent form, and

• You are willing to continue to participate in the study.