SPI Piloy Study Consent Form

3rd Person Version

Bureau of Justice
Statistics

Survey of Prison Inmates Pilot Study
Consent to Participate in Research
Consent Form
Introduction
The Survey of Prison Inmates Pilot Study is a research study being done by the Bureau of Justice
Statistics and RTI International, a not-for-profit research organization, located in North Carolina. You are
one of 80 inmates at this facility who have been randomly selected to participate. Inmates will be
interviewed at 6 facilities for this study. The purpose of this research project is to try out the procedures
and the questionnaire we’ve developed for conducting a national Survey of Prison Inmates in 2014. The
national survey will collect information on the conditions and experiences of inmates in the United States.
Your participation in this project is voluntary. After you have heard the information about the study, you
can decide if you want to answer the questions.

Description of the Study
This interview will take about 80 minutes. You will be asked questions about your criminal history,
physical and mental health, drug and alcohol use prior to incarceration, and any treatment you may have
received. You will also be asked questions about conditions at this facility, some background questions
about your family, and education and work history. The interviewer will record your answers in the
computer. In addition to asking you questions, we will review your criminal records. This review will
allow us to conduct additional research without taking up more of your time with questions.
[To thank you for participating in the study, we will provide you with a snack to eat before you leave this
room.]

Possible Risks or Discomforts
Some of the survey questions are personal and some of them ask about behaviors that may be illegal. It
is possible these questions may make you feel uncomfortable or upset. There are no right or wrong
answers and you can skip any questions you do not want to answer. If you become upset for any reason,
you can ask to stop the interview. Please tell the interviewer if you want to stop or take a break at any
time during the interview. If you find the survey questions to be upsetting for any reason, the interviewer
can also provide you with instructions for contacting a mental health counselor here at the facility.

Benefits
You will not receive any direct benefits for participating in this study. However, the results of this study
may help to improve the condition and well-being of inmates in correctional facilities across the nation.
If you choose not to participate you will not lose any benefits or services that you now receive or might
receive in the future. Whether you participate or not will not affect your legal status or any decisions
regarding your release from this facility in any way.

Confidentiality
As required by law, Title 42, United States Code, Section 3789g, this study is covered by a Privacy

Comment [rac1]: This sentence will be
removed if the facility is not willing for us to
provide the snack to their inmates.

3rd Person Version
Certificate which means that we will treat everything you say during the interview and all information
from your criminal record as private and any information that would identify you will be held strictly
confidential. It also means that nothing you tell the interviewer during the interview can be used in any
legal action. Your name will not be connected with the information you provide in this interview. We
will not share any of the information you provide with anyone outside or at the facility or anyone who is
not directly working on the project. There is, however, an exception to our promise of confidentiality. If
you tell the interviewer that you intend to seriously harm yourself or a specific person, he or she may need
to inform correctional staff.
Do you have any questions about taking part in this study?

Further Questions
You may keep a copy of this form. If you have any questions about the project, you may write to the
Survey of Prison Inmates Pilot Study at RTI International, P.O. Box 12194, Research Triangle Park, NC
27709-2194. If you have questions about your rights as a project participant, you can write to RTI's
Office of Research Protection at the same address.

If you would like to help us with our study by participating in the interview, please tell the interviewer
now and we will begin.

□

Willing to participate in the interview.

I certify that the nature and purpose, the potential benefits, and possible risks associated with participating
in this research have been explained to the participant.

□

I have read all required informed consent text to this individual.

Person Who Obtained Consent: ______________________________________
Headway ID Number: ________________
Date: _____/_______/_________