ENFG Employer Informed Consent

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

Employment Needs Focus Group—Employment Specialist

Informed Consent

Description of Participation: The Substance Abuse and Mental Health Services Administration (SAMHSA) is sponsoring a national evaluation of supported employment programs. The focus group activity is designed to learn more about the key components of these programs that support adults with serious mental illnesses, including persons with co-occurring mental and substance use disorders.

ICF has been funded by SAMHSA to conduct this evaluation.

We are asking you to take part in a discussion about these topics because you interact directly with consumers participating in a SAMHSA-funded supported employment program. Given your interaction, you can provide critical feedback about how these programs work and the employment needs of various stakeholders. The focus group will take no more than 60 minutes of your time. If you agree to participate, here are things you should know:

• Rights Regarding Participation: Your participation in the group is completely voluntary. There are no penalties or consequences to you for not participating. You may choose to leave the group and/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: For the focus group, we will ask you to use only your first name or an alternate name. We will take every precaution to protect your identity and ensure your privacy unless otherwise determined by law. Your name and answers to these questions will be kept private. Your contact information will be kept separate from any focus group responses. Your responses to the questions will not be attributed to you and your name will never be used in any reports. However, it is possible that your organization may be identifiable when results are reported.

• Benefits: Your participation in the focus group will not result in any direct benefits to you. However, your input will help to provide a better understanding of the SAMHSA Supported Employment program in your state and the employment needs of participants, employers, and employment specialists.

• Risks: The focus group poses minimal, if any, risks to you. None of the questions asked are of a sensitive nature, so none of them should make you uneasy.

• Audiotaping: The focus group will be audiotaped and transcribed to better understand what is said by each group member as you discuss the topics. Audio files will be kept in a password-protected database that is accessible to a limited number of individuals (selected ICF staff) who require it and who have signed confidentiality agreements. We will destroy the audio files at the end of the study.

Contact information: If you have any concerns about participating in the focus group or have any questions about the study, please contact Robin Davis, project director, at (404) 321-3211 or [email protected].

Please click the I CONSENT box below to proceed to indicate that you have read the above and agree to participate in the focus group.

• I CONSENT

• I DO NOT CONSENT

Do you agree to be audiotaped during the focus group? Please click the appropriate box below.

• I AGREE

• I DO NOT AGREE

Please provide the following contact information to be contacted for the focus group.

Email Address: ___________________________________________________________

Phone Number: ___________________________________________________________

2