Client Consent Form

OMB No. 0930-####

Expiration Date: ##/##/####

Consent Form for Participation in the VITEL Program Evaluation

CLIENT FOCUS GROUP

A. Background and purpose

XXXX has a contract with the Substance Abuse Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) to conduct a Study of the VITEL program. The XXXX Team is not part of CSAT or any other federal agency.

The purpose of this study is to learn more about the effect of IPV screening and referral, substance use disorder treatment, and HIV services supported by VITEL funding. The goal of the study is to reduce IPV risk, substance use/abuse, and among racial and ethnic minority women at risk for or living with HIV/AIDS. Information from your participation will help the XXXX team understand how programs can better reduce IPV, substance use/abuse, and HIV risk behaviors.

You are being asked to participate in this study because you are a client who receives services from a VITEL program.

B. Procedures

If you agree to participate, the following will occur:

• You will take part in a focus group discussion. The focus group will be about your experiences and opinions about this program.

• The discussion will last approximately 60 minutes.

• The group discussion will take place at a time and location convenient to you.

• You will complete a form providing background information (e.g., your age, gender) and information about your satisfaction with your VITEL program.

• Total time commitment will be approximately 90 minutes.

• The discussion will be audio-taped to ensure accuracy in reporting your statements. No names or identities will be used in any published reports.

All information you provide is anonymous. Input you provide during the discussion will be combined with information from other focus groups from across the United States. The combined information will be analyzed. Only combined results will be presented in reports.

C. Risks

There is a small risk of loss of privacy. However, extra measures will be taken to protect each participant’s privacy. No names or identifiers will be used in any study reports. Also, the XXXX team member leading the discussion will begin by asking the participants to agree to the importance of keeping information discussed in the focus group confidential. Only the XXXX team will have access to information from the discussion. There is a risk that you may feel uncomfortable with some of the questions asked. However, you can answer only the questions you choose to answer.

Notice to Respondents

Public Burden Statement: 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-xxxx. Public reporting burden for this collection of information is estimated to average 60 minutes per respondent, per year, 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, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

D. PRIVACY

The information that you provide will be kept private. The Interview discussion will not be shared with anyone but the researchers conducting this study, except as otherwise required by law. All of the data will be kept in locked files at XXXX. The consent form that you sign will be kept in a locked file separate from your participant information form. Only the official program staff will have access to these files. At the end of the program all data will be given to CSAT. The data that is given to CSAT will not include names or participant identification.

E. BENEFITS

There is no direct benefit to you for participating in this research program. However, the information you share may benefit your VITEL program and similar programs targeting persons similar to you.

F. COMPENSATION

You will be given a $20 gift card for your participation in this focus group.

G. Right to Refuse or Withdraw

Your participation in this focus group is completely voluntary. You may leave the focus group at any time. If you refuse to participate, there will be no penalty or loss of benefits to you.

H. Persons to Contact

If you have any questions about this study, please contact XXXX XXXXX at XXXX.

Name

XXX Main Street

XXXXX, NY10036

(XXX) XXX-XXXX

[email protected]

If you have any concerns about your rights in this study or questions about injuries related to the research program, please contact XXXX XXXXX of the [XXXX ] Institutional Review Board.

Name

XXX Main Street

XXXXX, NY10036

(XXX) XXX-XXXX

[email protected]

I. Your Consent

You have read this consent form. You have been given a chance to ask questions, and feel that all of your questions have been answered. You know that you are free to participate in the focus group or not. You know that after choosing to participate in the focus group, you may drop out at any time without penalty. You are signing below because you agree to participate in this focus group. You give permission for your responses to be audio-recorded.

_____________________________________ __________________

Participant’s Name (Print) Date

_____________________________________

Participant’s Signature

I acknowledge that I witnessed the participant sign this consent form.

_____________________________________ __________________

Witness’ Name (Print) Date