Form Screening

2015 NSDUH, Supporting Statement
Attachment Q – Federalwide Assurance

http://ohrp.cit.nih.gov/search/IOrgDtl.aspx

2015 NSDUH, Supporting Statement
Attachment T – Quality Control Form

QUALITY CONTROL FORM
NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 2 minutes per response,
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,
Paperwork Reduction Project (0930-0110); Room 2-1057; 1 Choke Cherry Road, Rockville, MD 20857. 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 0930-0110.

OMB No.: 0930-0110
OMB Expiration Date:
09/30/16

VERSIÓN EN ESPAÑOL AL REVERSO
As part of our quality control program, we plan to contact a portion of the survey participants to
make sure that the interviewer has followed the study procedures. We only ask general
questions—no specific information is required. We sincerely appreciate your cooperation.
Please fill in the boxes below. (PLEASE PRINT CLEARLY.) Thank you.

[Your phone number will be kept confidential and will not be released to anyone other than our
quality control representatives.]
TELEPHONE
NUMBER

_

_

(Area Code)

(Telephone Number)

YOUR
ADDRESS
CITY

ZIP
CODE

STATE

BOXES BELOW MUST FIRST BE COMPLETED [IN INK] BY INTERVIEWER.
TODAY’S
DATE

M

M

_

D

D

_

1

FI
NAME
CASE
ID #

5

TIME

.
.

AM
PM

FI
ID #
_

_

_

Include
A or B!

IF respondent is 12 - 17 years old, which
adult granted permission for the interview? 
(Examples: father, mother, etc.)

[Print Parent/Guardian’s relationship to the child in this box.]

2015 NSDUH, Supporting Statement
Attachment E – Lead Letter

UNITED STATES DEPARTMENT OF HEALTH & HUMAN SERVICES
ROCKVILLE, MD 20857

[NAME County/Parish/District] Resident at:
1234 Main Street
Anywhere, XX 12345

Dear [NAME County/Parish/District] Resident:
The U.S. Department of Health and Human Services is conducting a study called the National
Survey on Drug Use and Health. This study asks questions about use or non-use of alcohol,
tobacco and other substances. The study also asks about mental health and other health-related
topics relevant for all people. Since 1971, this information has been used by local, state and
national agencies for planning and providing treatment and prevention programs.
Your address was randomly chosen, through scientific methods, along with almost 200,000
others across the country. RTI International, a nonprofit organization, was selected to conduct
this study. Soon, an RTI interviewer will be in your neighborhood to give you more information.
The interviewer will carry an identification card like the example shown below.
First, the interviewer will ask a few general questions. Then the interviewer may ask one or two
members of your household to complete the full interview. It is possible no one will be chosen
to be interviewed. If anyone is chosen and completes the full interview, he or she will
receive $30 in cash.
By Federal law*, the answers you give will be kept confidential and will be used only for
statistical purposes.
Please share this information with any others in your household. Feel free to ask the interviewer
any questions you have about this study. More information is also available on the study website
at: http://nsduhweb.rti.org or you may contact us at 1-800-848-4079.
Your help is very important to this study’s success. Thank you for your cooperation.
Sincerely,

Joel Kennet, Ph.D.
National Study Director, DHHS

Ilona S. Johnson
National Field Director, RTI
You will be contacted by: ___________________________________________
Interviewer Name
*Confidentiality protected by the Confidential Information Protection and Statistical Efficiency Act of 2002 (PL 107-347)
Authorized by the U.S. Congress as part of Section 505 of the Public Health Service Act (42 USC 290aa4)
Approved by Office of Management and Budget (OMB Approval No. 0930-0110)

2015 NSDUH, Supporting Statement
Attachment J – Contact Cards – Sorry I Missed
You and Appointment Cards

Sorry I
Missed You…

Sorry I
Missed You…

Dear Resident:

Dear Resident:

I stopped by today to talk to you about an
important research study being conducted by RTI.

I stopped by today to talk to you about an
important research study being conducted by RTI.

I am sorry that I did not find you at home. I will
return to talk with you in the next few days.

I am sorry that I did not find you at home. I will
return to talk with you in the next few days.

Thank you in advance for your participation.

Thank you in advance for your participation.

Sincerely,__________________________________

Sincerely,__________________________________

Date: ________________ Time: ______________

Date: ________________ Time: ______________

2015 NSDUH, Supporting Statement
Attachment K – Study Description

Study
Description
Your address is one of several in this area randomly chosen for the 2015 National
Survey on Drug Use and Health. This study, sponsored by the U.S. Department of
Health and Human Services, collects information for research and program planning by
asking about:
• tobacco, alcohol, and drug use or non-use,
• knowledge and attitudes about drugs,
• mental health, and
• other health issues.
You cannot be identified through any information you give us. Your name and address
will never be connected to your answers. Also, federal law requires us to keep all of
your answers confidential. Any data that you provide will only be used by authorized
personnel for statistical purposes according to the Confidential Information Protection
and Statistical Efficiency Act of 2002.
The screening questions take just a few minutes. If anyone is chosen, the interview will
take about an hour. You can refuse to answer any questions, and you can quit at any
time. Each person who is chosen and completes the interview will receive $30
in cash.
If you have questions about the study, call the Project Representative at 1-800-8484079. If you have questions about your rights as a study participant, call RTI’s Office of
Research Protection at 1-866-214-2043 (a toll-free number). You can also visit our
project website: http://nsduhweb.rti.org/ for more information.
Thank you for your cooperation and time.

Peter Tice, Ph.D.
Project Officer
Center for Behavioral Health Statistics and Quality
Substance Abuse and Mental Health Services Administration (SAMHSA)
U.S. Department of Health and Human Services
Your confidentiality is protected by the Confidential Information Protection and Statistical Efficiency Act of 2002
(CIPSEA, PL 107-347). Any project staff or authorized data user who violates CIPSEA may be subject to a jail
term of up to 5 years, a fine of up to $250,000, or both.
NOTICE: Public reporting burden for this collection of information is estimated to average 60 minutes per response, 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, Paperwork Reduction Project (09300110); Room 2-1057; 1 Choke Cherry Road, Rockville, MD 20857. 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 0930-0110, expiration date 09/30/16.