Qualitative Interview Consent Form

CROSS-SITE EVALUATION OF MENTAL HEALTH FIRST AID
Consent for Participation in Study

Purpose
The purpose of this study is to collect information about the implementation of Mental Health First Aid/Youth
Mental Health First Aid (MHFA/YMHFA) in Project AWARE grant programs funded by the Substance Abuse and
Mental Health Services Administration (SAMHSA). The goal is to develop a better understanding of factors
associated with the adoption and quality utilization of MHFA/YMHFA within states, districts, and/or
communities. This study is conducted by the American Institutes for Research (AIR) on behalf of SAMHSA.
What We are Asking of You
You have been identified as someone who is knowledgeable about MHFA/YMHFA on a state or local level. We
are asking you to participate in a 45 minute telephone interview about contextual factors that are important
for adopting and implementing MHFA/YMHFA with quality.
Risks
There are no anticipated or known risks in participating in this study beyond those ordinarily encountered in
daily life.
Benefits
Your participation in the study will contribute knowledge about the strategies to optimize implementation of
MHFA/YMHFA in states, districts, and/or communities throughout the nation.
Freedom to Withdraw
Your participation in this study is completely voluntary. You may skip any question or discontinue participation
altogether without any penalty.
Privacy
The information collected for this study is not of a private or personal nature. In our study report, we may give
examples using state, district, and/or community names for particular topics that you may have shared with
us. We will not identify you by name, but readers familiar with MHFA/YMHFA may be able to deduce your
identity from the information shared.
Audio Recording
With your permission, we would like to make a recording of our interview to be sure we have accurately
captured the information you share. We will not release the recordings to anyone outside the study team, and
the recordings will be deleted at the end of the study.
More Information
If you would like more information about these interviews, you may contact Dr. Kimberly Kendziora at
[email protected] or at (202) 403-5391. For questions regarding your rights as a participant in this research,
please contact the Institutional Review Board (IRB) at [email protected] or toll free at 1–800–634–0797.
Informed Consent
If you have read the above information, asked any questions and received answers, and agree to participate in
the study, please sign below.
OK to record the interview?

Yes

No
Signature: ________________________________

Date: ________________________

Print Name: ______________________________

District/Organization:________________________