TUP-S Consent to Contact (RCT) StateTribal

OMB No. XXXX-XXXX

Expiration Date: Date

Garrett Lee Smith (GLS) National Outcomes Evaluation

State/Tribal Suicide Prevention Program

Training Utilization and Preservation Survey (TUP-S)

Consent to Contact Form (RCT)

Training ID: 

Training Name:

Date of Training/Today’s Date:

As part of the of GLS National Outcomes Evaluation of suicide prevention programs, we will be interviewing individuals who participated in suicide prevention training activities like the one for which you have signed up. The Training Utilization and Preservation Survey is a telephone survey that will be administered to participants of suicide prevention gatekeeper training programs to collect information about gatekeeper knowledge, attitudes, and behaviors following their trainings. We will ask you to participate in a survey four times over a 1-year period to learn about how you used what you learned over time:

1. The first survey will be administered to your BEFORE you participate in the suicide prevention training.

2. The second survey will be administered to you 3 months AFTER you participate in the suicide prevention training.

3. The third survey will be administered to you 6 months AFTER you participate in the suicide prevention training.

4. The second survey will be administered to you 12 months AFTER you participate in the suicide prevention training.

Your participation in these brief surveys is completely voluntary. Your answers to the survey questions will be kept private, except as otherwise required by law. Your name will not be linked with the information on your survey. Your name will not be used in any reports about this evaluation. We are interested in contacting you again for four surveys over the next 12 months to ask you some questions about what you learned during this training; how you have used what you learned; and what impact it has had on your identification and referral of youths at risk for suicide in your community. Findings from the survey will assist in informing SAMHSA (which stands for the Substance Abuse and Mental Health Services Administration) about suicide prevention activities and training experiences.

The surveys will each take approximately 20–30 minutes and will be conducted over the telephone by a member of the National Outcomes Evaluation team. If you are selected to participate in the interview, in appreciation of your time, we will provide you with either a $10 Amazon gift code or we will mail you a $10 money order.

Are you interested in being contacted for participation in the four Training Utilization and Preservation Surveys?

• Yes

• No

If you are interested in participating in this important effort, or in learning more about the Training Utilization and Preservation Survey, please provide your contact information below. A member of the National Outcomes Evaluation team will contact you to complete your survey.

Name:
Cell Phone:		Best Contact?			Best Time to Call?
		Yes		No	AM	PM
Work Phone:		Best Contact?			Best Time to Call?
		Yes		No	AM	PM
Home Phone:		Best Contact?			Best Time to Call?
		Yes		No	AM	PM
Work E-mail:
Personal E-mail:
Preferred Language for Survey	English		Spanish

If you have any concerns or questions about your participation in this study, please contact Christine Walrath, principal investigator, at (212) 941-5555 or [email protected].

Thank you!

State/Tribal TUP-S Consent to Contact (RCT) 1

12/2015