Stakeholder Survey Consent Form

Attachment 7: Stakeholder Survey Consent Form

OMB No. 0930-0320

Expiration Date 03/31/2014

Consent to Participate in an Evaluation Study

Substance Abuse and Mental Health Services Administration (SAMHSA)

Evaluation of SAMHSA Homeless Programs

Stakeholder 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) Homeless Programs throughout the country. SAMHSA’s Homeless Programs include Grants for the Benefit of Homeless Individuals (GBHI) and Services in Supportive Housing (SSH) grants. The evaluation will examine the effects of the SAMHSA Homeless Programs project activities on client outcomes, treatment services, service systems and cost-effectiveness and identify challenges and successes in implementing and sustaining a program for homeless or housed individuals who have substance abuse or mental health problems or both. 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 nominated by a GBHI/SSH grantee as someone knowledgeable about the local SAMHSA Homeless Programs project in your community. Your perspectives on your local SAMHSA Homeless Programs project and services are vital in helping SAMHSA improve its Homeless Programs and the supports local projects offer to clients.

The following questions ask about your experiences as a stakeholder partner to a current local SAMHSA Homeless Programs project, [Project Name], that was implemented in [city, state], by [agency name] on [date]. These questions are designed to gather background information about your agency, the services provided, and your experience partnering on the implementation and sustainability efforts of the local SAMHSA Homeless Programs project.

Voluntary Participation and Privacy

Your decision to take part in this evaluation study and your participation is completely voluntary. You may refuse any part of the study and you may stop participating at any time. You may 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. RTI will track surveys by organization to ensure outreach to all project partners, but will assign an organization-level code and random respondent code to each survey. We will not document your name and we will not be able to connect your survey responses to your name. At no time will your employer or anyone else not connected with the research see your responses. When the results of this study are presented in reports or at scientific meetings or published in scientific journals, no information will be included that could identify you or your answers personally or directly identify your agency.

Risks and Benefits of the Study

There are no known risks of participation in this online web survey. It will take about 17 minutes of your time including review of this consent. There are also no immediate benefits of participation. No incentive for participation is provided. Information from key stakeholders like you will be aggregated and the findings may help stakeholders, practitioners, policy makers, researchers, and funders learn more about the efforts of local SAMHSA Homeless Programs 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 evaluation Project Director, toll-free at 1-877-653-1240. Leave a message and she will return your call. You may also email Dr. Broner at [email protected].

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 may write to them at RTI International Office of Research Protections, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, North Carolina, 27709-2194.

By clicking on Consent 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.