informed consent

Attachment 4

Voluntary Informed Consent

You are being asked to participate in a research study because you are receiving services at [Insert Name of Program]. The research is being conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal government agency that provides funding for some of the services provided at this program and by researchers at the School of Social Work at the Catholic University of America.

SAMHSA and the Catholic University of America are conducting research to see how people who receive services at this and other similar programs are doing in terms of different aspects of their life such as work, living conditions, health including alcohol and drug use and, relationships with family and friends.

Information that will be collected from you: As part of this research you are being asked to participate in two short interviews where you will be asked approximately 20 questions about yourself. These interviews will be conducted near the time that you enter the program and then 6 months later. The interviews will take about 10 minutes to complete.

Your responses to these interviews will be confidential. After the interviews are completed your responses will be forwarded by your program staff to SAMHSA. Your responses will be identified by a number that will be known only to the program staff. By using this confidential identification number we will be able to match your answers to this short study to information you provide routinely to your program staff.

Once you sign this consent form, program staff will send it to SAMHSA for storage. This information will be protected by SAMHSA staff, and only the project director will have access to it. She will store it in a locked file cabinet, and will destroy it at the end of the study.

Initial Here ______________

Risks and benefits: There are no known risks associated with participating in this study. However because of the personal nature of some of the questions some you may experience feelings of minor discomfort.

Participation in this study will not benefit personally. However, it is anticipated that the findings from this study will be used by people in the mental health and substance abuse fields to develop and provide better services for people in need.

There are no costs for participating in this study and there will be no monetary payments for participation.

Voluntary nature of your participation: You do not have to take part in this study, and your refusal to participate will involve no penalty or loss of services or benefits to which you are entitled. You may withdraw from this study at any time without penalty or loss of services or benefits to which you are entitled.

Any information obtained as a result of my participation in this research study will be kept as confidential as legally possible.

The results of this study may be published, but your records will not be revealed unless required by law.

If you have any questions or concerns about this project, or believe that your rights have been violated in any way, please contact Dr. Alyson Essex at the Substance Abuse and Mental Health Services Administration at 24-276-0529 or [email protected].

If you have any questions about the conduct of this study or your rights as a subject in this study, you can call The Catholic University of America, Office of Sponsored Programs at 202-319-5218.

I have read or have read to me all of the above.

________________________________ has explained the study to me and answered all of my questions. I have been told of the risks or discomforts and possible benefits of the study.

_________________________________________________

Signature of Subject Date

__________________________________________________

Signature of person obtaining consent Date