Form Client Initial Scr Client Initial Scr Client Initial Script

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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.

Cohort V Client Initial Request Script

Telephone Script for Obtaining Client’s Approval for Research Re-contact

“Before we hang up, I’d like to describe a telephone research survey that is being conducted with people who receive follow-up from a crisis line. The reason for doing the interview is to find out how people are doing in the weeks after we talked to them and to see if crisis centers are providing effective services to their clients. Our center is working with researchers at Columbia University to do this telephone assessment. For purposes of consent, the study has to be limited to people who are 18 years of age or older.”

1) Are you 18 years of age or older?  Yes (18 years or older)  No (younger than 18 years)

IF CLIENT IS YOUNGER THAN 18 YEARS OF AGE, PLEASE DO NOT REQUEST PERMISSION FOR RE-CONTACT

“Right now, we would just like to find out whether it is okay for the research/evaluation team from Columbia University to call you to tell you more about the study. They would be calling you about 6 weeks past the time you were referred to us for follow-up. May someone from Columbia University call you to see if you might be interested in participating in the telephone research survey? Only some clients will be re-contacted for the survey. The selection of the clients will be random (like flipping a coin) and has nothing to do with you personally. If they call you they will give you all the details about the research. While they need your name to call you back, your name will not be connected to any of your answers on the survey or any reports that come out of the evaluation project. The survey will take about 30 to 40 minutes and you will be paid $50 for helping with this evaluation.”

PLEASE FILL IN BLANKS AND CHECK APPROPRIATE BOXES:

2) Client’s Gender:  Male  Female  Unknown

3) Client’s Age: ___________  Unknown

4) Date of Client’s Referral for Follow-up: _____/_____/_____ (mm/dd/yy)

5) Client was referred for follow-up subsequent to: (please choose one)

 ED discharge  Inpatient discharge  Other: ________________

6) Date of Follow-up Call during which request was made: _____/_____/_____ (mm/dd/yy)

7)  Client Agreed  Client Refused

8) ____________________________________ ________________________________________

Signature of Person Asking for/Obtaining Approval Printed Name of Person Asking for/Obtaining Approval

ONLY PROVIDE NAME AND REMAINING INFORMATION BELOW IF CLIENT HAS AGREED:

9) Client’s Name: ____________________________________________________________________

Contact Details for Columbia’s Call:

 Cell phone

10) Telephone number for Columbia’s call: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

11) Best days & times to call: ____________________________________________________________

 Cell phone

12) Alternate number for Columbia’s call: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

13) Best days & times to call: __________________________________________________________

14) “If you have Caller ID, should they block their identity when they call you?”  Yes  No  N/A -

no caller ID

15) If you don’t pick up when Columbia University calls, is it okay for them to leave a voicemail message? They could say, "This is Columbia University calling to see if you'd be interested in participating in a telephone survey," or they could leave a different message.

 Do Not Leave Message

 Leave Columbia Message

 Leave Different Message: (If yes, write down exact message to be left:)

______________________________________________________________________

______________________________________________________________________

16) If someone else answers when Columbia University calls, is it okay for them to leave a message with the person who answers the phone? They could say, "This is Columbia University calling to see if you'd be interested in participating in a telephone survey," or they could leave a different message.

 Do Not Leave Message (If yes, skip to question 17)

 Leave Columbia Message

 Leave Different Message: (If yes, write down exact message to be left:)

______________________________________________________________________

______________________________________________________________________

16a) IF OKAY TO LEAVE A MESSAGE: Is it okay for Columbia University to ask this person for your new telephone number, if your number has changed?  Yes  No

17) If your phone number changes before Columbia University is able to reach you, is there someone else they can call to ask for your new telephone number?  Yes  No (If “No,” form is complete.)

(If “Yes,” please provide the names and phone numbers of up to 3 back-up contacts, and answer 17a.)

Name _____________________________ Tel. #:(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

Name _____________________________ Tel. #:(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

Name _____________________________ Tel. #:(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

17a) When Columbia University reaches your backup contacts, they could say, “This is Columbia University calling to see if he/she would be interested in participating in a telephone survey,” or they could say something else.

 Use Columbia Message

 Use Different Message: (If yes, write down exact message to use:)

_________________________________________________________________

_________________________________________________________________

THANK YOU! WE VERY MUCH APPRECIATE YOUR COLLABORATION ON THIS PROJECT.