SSA KII Verbal Consent Script

OMB No: XXXXX

Expiration Date: XXXX

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 XXXX-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.

Community Support Evaluation: Supported Employment

Scalability/Sustainability Assessment Key Informant Interview

Verbal Consent Script

Description of Participation: The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services is sponsoring a national evaluation to learn more about the key components that enable states to establish, sustain, and expand evidence-based Supported Employment programs for adults with serious mental illnesses including persons with co-occurring mental and substance use disorders in communities across the state.

ICF has been funded by SAMHSA to conduct this evaluation. The purpose of this interview is to understand your role in the SE program and specific information about the program you may be able to provide. The interview will take approximately 60 minutes to complete.

We would like to get your permission to record this interview to ensure that we accurately capture details that you provide. However, if you do not agree to be recorded, we will not record the interview. If you agree to be recorded, only ICF staff will be able to use the recording. To protect your privacy, we will keep the notes and recordings in private files and only ICF study staff members will be allowed to use them. All recordings will be destroyed after the data has been analyzed and reported. Do I have your permission to record the interview?

• YES

• NO

Rights Regarding Participation: Your participation in this interview is completely voluntary. There are no penalties or consequences to you for not participating. You may choose to stop the interview or not answer a question at any time for any reason. You may contact the evaluation principal investigator with any questions you have before, during, or after completion.

Privacy: We take every precaution to protect your identity and ensure your privacy unless otherwise determined by law. Contact information will be entered into a password-protected database that is accessible to a limited number of individuals (select ICF staff) who require it and have signed confidentiality agreements. Your responses to the interview will not be attribute to you and your name will never be used in any reports. However, it is possible that your agency may be identifiable when results are reported.

Benefits: Your participation in this interview will not result in any direct benefits to you. However, your input will help to provide a better understand of the Supported Employment program.

Risks: This interview poses minimal, if any, risks to you. As a reminder, your name will not be attributed to your responses and it will not be used in any reports, but your agency may be identifiable in reported results. Also please remember you may elect to stop the interview or not answer a question at any time for any reason.

Contact information: If you have any questions about this evaluation, please contact:

Robin Davis, Project Director
ICF International
Telephone: (404)-592-2188
3 Corporate Square, NE, Suite 370, Atlanta, GA 30329

By agreeing to participate in this interview, you certify that you understand the information I have provided to you and you freely agree to participate. Do you consent to participate in this interview?

• YES

• NO

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