Consent Form

OMB No. 0930-0196

Expiration Date: 09/30/2019

Attachment C

Intervention Resources Focus Group Authorization and Release

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 Office Management and Budget (OMB) control number. The OMB control number for this project is 0930-0196. The public reporting burden for this collection of information is estimated to average 90 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 the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.

Center for Substance Abuse Treatment

Division of Pharmacologic Therapies (DPT)

5600 Fishers Lane, Rockville, Maryland 20857

Phone 240-276-1660 Fax 240-276-1670

Authorization and Release

The undersigned hereby authorizes the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) to use the information, feedback, and opinions I provided through a focus group on the development and design of two public education resources for parents: one in the area of intervention to prevent the escalation of substance use to addiction among youths and young adults, and another for parents who are experiencing overdose bereavement.

__________________________________________

Full Name of Adult (18+ years old)

_____________________________ _________________________________

Signature of Adult Date

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Address

___________________________________ __________________________________

Phone Number Date

The Division of Pharmacologic Therapies (DPT), part of the SAMHSA Center for Substance Abuse Treatment (CSAT), manages the day-to-day oversight activities necessary to implement federal regulations on the use of substance use disorder medications such as methadone and buprenorphine. These activities include supporting the accreditation and certification of opioid treatment programs (OTPs) and treatment of patients.

Center for Substance Abuse Treatment promote community-based substance abuse treatment and recovery services for individuals and families in every community. CSAT provides national leadership to improve access, reduce barriers, and promote high quality, effective treatment and recovery services.

Visit http://www.samhsa.gov/about-us/who-we-are/offices-centers/csat and http://www.samhsa.gov/medication-assisted-treatment/about for more information.

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