Form Client Follow-up C Client Follow-up C Client Follow-up Consent Script

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 10 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 Client Follow-up Consent Script

Briefly introduce yourself and explain the purpose of your call. Remind the client that when he/she received a follow-up call from (name of crisis center) he/she said it would be okay for us to call him/her to see if he/she might be interested in participating in a research study involving a follow-up telephone survey: Ask the client if he/she feels well enough to talk at this time.

Read the following to the client:

Purpose and Overview

I would like to explain what this research survey is about. You can interrupt with questions at any time. _________________ (name of crisis center) is working with Columbia University researchers at the New York State Psychiatric Institute (NYSPI) on a research study that is sponsored by a federal agency, the Substance Abuse and Mental Health Services Administration. We are doing this follow-up telephone survey because it will help us find out whether crisis hotlines provide effective services to the people they follow-up with. You are being asked to participate because you received telephone follow-up services from a crisis center.

Voluntary

Participation in this research study is voluntary. You can refuse to answer any or all of the questions. You can stop at any time. If you decide not to participate, or if you later decide to stop participating, you will not be penalized in any way.

Procedures

The purposes of this telephone survey are to find out how you have been doing since you received a call from _________________ (name of crisis center), and to ask your permission to access information from their records and from the hospital’s records about your circumstances at the time you were referred for follow-up.

During this survey, we will ask you some questions to find out what you were going through when you were referred for follow-up from the crisis hotline on ______________ (date of referral for follow-up), how you have been feeling since you spoke with them, and how you are feeling now. We will ask you about the referral(s) that the crisis hotline counselor gave to you, and whether you've been able to follow up with the referral(s). We will also ask you whether you have accessed any other resource for help either before or after you spoke with the crisis counselor.

Risks and Inconveniences

A risk of participating in the survey is that while answering the survey questions, you may think about the concern that prompted you to accept follow-up from the crisis line and the emotional distress you were experiencing at that time. While talking about that experience, you may become distressed again and may feel the need for additional support. I am not an employee of the crisis service, but I am a trained crisis worker and can put the interview on hold and discuss your feelings and concerns with you. After this, you may decide to continue the interview, postpone it to another time, or decide not to complete it.

Benefits

The benefits of participating in the survey may include the opportunity for you to discuss how you have been doing since your contact with the crisis center, or to clarify the plan that you and the counselor came up with. In addition, your responses can help improve the quality of services offered by the crisis hotline.

Before I discuss privacy, do you have any questions about what I have said so far?

Confidentiality

We are very concerned about keeping your answers private. We will not put your name on the survey. It will refer to you only by a study number. Data in our computers will contain only this number, not your name. Be assured that neither you, nor anyone else taking part in the study will be identified by name in any publication or report of the findings. NYSPI is a health care institution subject to the Health Insurance Portability and Accountability Act (HIPAA). All of our project staff have signed a privacy statement saying that they will keep your answers private and taken training related to the privacy and security of information collected for this research. Our project staff will be the only people who can link your study number with your name.

All records that link your name with your study number will be kept in locked files in our offices at the New York State Psychiatric Institute (NYSPI) and will be kept private to the extent permitted by law. However, if we learn about serious harm to you or someone else, as in cases of abuse, we would have to take whatever measures are needed to protect the individuals involved, including reporting to appropriate protective services. Other kinds of problems are thoughts about killing yourself or doing things to cause serious harm to yourself on purpose. In these kinds of situations, we would be obligated to refer you back to the hotline for intervention. This would involve our contacting the hotline to immediately implement their routine procedures for handling emergencies.

Study Compensation

If you decide to participate in the telephone research survey, we will schedule the survey at a time that is good for you. We can do it right now, if this is a convenient time for you. The survey will take approximately 30 to 40 minutes. We will send you $50 to thank you for taking the time to talk with us. We will mail you a money order soon after you have finished the survey. It will take about two to three weeks for you to receive the money order.

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 S. Gould at (646) 774-5763. 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). (An IRB is a committee that protects the rights of human subjects in research studies). You may call the IRB Executive Director at (646) 774-7161 during regular office hours.

Do you have any questions? Are you willing to take part in the telephone research survey? I will be turning on a tape recorder to record your answer about agreeing to participate.

Documentation of Consent

___________________________ (Subject’s name), do you voluntarily agree to participate in the telephone research survey for the Hotline Follow-up Evaluation Study?

Agreed_________ Refused_________ Date__________________________________

Do you agree to have us access information from the crisis center that followed up with you about the circumstances of your accepting follow-up and about your risk status at that time, and to have us associate that information with your survey answers?

Agreed_________ Refused_________ Date__________________________________

Do you agree to have us access information from the ED/hospital you visited about the circumstances of your ED/hospital admission(s), and to have us associate that information with your survey answers?

Agreed_________ Refused_________ Date__________________________________

Note to Interviewer: If caller answers “No” to any of the above, please ask the following:

Unless you object, we would still like to access information about your ED/hospital admission(s), and about your risk status at the time you were receiving follow-up from the center, for the purpose of generating general, statistical knowledge about crisis center follow-up clients. This information will not identify you in any way. Do you agree to allow us to use this information in this way?

Agreed_________ Refused_________ Date__________________________________

IF THIS INTERVIEW WAS SELECTED FOR TAPING, please also obtain the consent for taping below:

In order to keep track of the quality of the survey, we would like to tape record the survey with you. No information that can identify you will be on the tapes. The tapes will be erased at the end of the project. If you say “no,” you can still take part in the research survey and you will still receive $50. Do you agree to let me tape this survey?

Agreed__________ Refused________ Date____________________________________

SIGNATURE:

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

Signed: _______________________________________ Date________________________

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