Form Counselor Consent Counselor Consent Counselor Consent

Gould protocol #6895R rev. 03/16/16

OMB No. 0930-0274

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 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 5 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Suicide Prevention Hotline Follow-up Evaluation

Cohort V Counselor Consent for Questionnaires

Purpose and Overview

This research project, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), has been designed to evaluate SAMHSA's cooperative initiative with the National Suicide Prevention Lifeline to provide follow-up to suicidal hotline clients and at-risk individuals discharged from hospital emergency rooms and inpatient units. You are being asked to participate because your role at your crisis center includes conducting follow-up calls with suicidal individuals, and because your center has been selected by SAMHSA to be one of the centers that are part of this research.

Voluntary

Participation in this research study is voluntary. There will be no penalty if you do not want to take part in the study. You are free to withdraw from this study at any time with no consequence to you by calling the study Principal Investigator (contact information is provided below).

Procedures

In the course of the study, you will be asked to complete a self-administered questionnaire for each client you attempt to follow. This questionnaire asks about the circumstances of the client’s referral for your follow-up, whether contact is successfully made with the client, clinical activities conducted during follow-up, any additional treatment referrals you offer the client, to what extent the client follows through with referrals, and how the client is doing at the time of follow-up. The questionnaire will also ask about your prior training, level of education, and experience as a telephone crisis counselor, information which you will be asked to provide only once.

Risks and Inconveniences

No risks are anticipated from your participation in this research. A breach of privacy is possible, but as we describe below, we have taken precautions to minimize this risk.

Benefits

This study is not designed to benefit you. However, your center may request reports and follow up consultation from the researchers that can inform and enhance your services to individuals in crisis. (No individual counselor or client will be identified in these reports.) Providing independent evaluation data to potential funding sources may enhance your center’s ability to obtain funding and sustain its critical services. Furthermore, it is hoped that the study will provide a broader benefit to society. Previous research shows that seriously suicidal individuals call crisis hotlines, and that calls to crisis hotlines are associated with reductions in crisis and suicidal states. This study is designed to help optimize telephone crisis services as a suicide prevention strategy by evaluating how follow-up with suicidal clients may improve client outcomes. In the long run, such findings may encourage federal and non-profit investment in the most effective crisis line services.

Confidentiality

We are very concerned about maintaining the privacy of the data you provide to us. For the purpose of linking your questionnaires, your name and the name of your center will be temporarily recorded on questionnaires returned to us by mail or fax. Questionnaires may also be returned to us via email, in which case only your initials should be recorded on the form. When we receive your questionnaires, we will delete your name or initials and the name of your center and refer to you and your center only by study numbers. Data in our computers will contain only study numbers, not any names or pseudonyms. Only group data that has no identifying information will be presented at meetings or in reports.

All records will be stored in locked files in our offices at Columbia University and will be kept private to the extent permitted by law. Records will be available to research staff, and to Federal, State and Institutional regulatory personnel (who may review records as part of routine audits). We will destroy the records at the end of the project.

Questions

The researchers will answer to the best of their ability any questions that you may have now or in the future about this study and your participation in it. If you have any questions or concerns about any aspect of the project, you may call the Principal Investigator Dr. Madelyn Gould at (646) 774-5763.

The Institutional Review Board of the New York State Psychiatric Institute-Columbia University Department of Psychiatry (NYSPI-IRB) has approved the recruitment of subjects for this study, as indicated by the stamp at the bottom of the form. If you have any questions about your rights as a research participant, want to provide feedback, or have a complaint, you may call the NYSPI Institutional Review Board (IRB). You may call the IRB Executive Director at (646) 774-7161 during regular office hours.

Documentation of Consent

I voluntarily agree to participate in the research study described above.

Print Name_____________________________________________

Signature_______________________________________________Date__________________

I have discussed the proposed research with this participant including the risks, benefits, and alternative to participation (i.e., the alternative of not participating in the research). The participant has had an opportunity to ask questions and in my opinion is capable of freely consenting to participate in this research.

Print Name_____________________________________________

(person designated to obtain consent)

Signature_______________________________________________Date__________________

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