CRS Adult and Adolescents Materials

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National Mental Health Study (NMHS) Field Test

CRS Adult and Adolescents Materials

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National Mental Health Study Field Test,
Supporting Statement
Attachment M-1 – CRS Data Collection
Materials

CRS Data Collection Materials

NMHS CRS Reminder Card

Adolescent CRS Follow-up
Study Description
U.S. Department of Health and
Human Services
You have been picked to take part in one additional interview by telephone for the National Mental
Health Study (NMHS). This study is sponsored by the U.S. Department of Health and Human Services
(DHHS). The interview will have questions about many common mental health issues that adolescents
may face. These issues include sadness, fears, and attention problems, as well as the use of drugs or
alcohol, and experiences with and exposure to crime and violence. Your parent said you can do this
interview if you want to. It is your choice whether or not you do the interview. It takes about an hour.
If you choose to do the interview, we will ask for your first name and your parent’s first name, and a
telephone number. This information will only be used by another interviewer who will contact your
parent and you in the next couple of weeks about completing the interview.
Federal law keeps your answers private. This is true except for two things. If you tell the interviewer
that you plan to harm yourself or someone else, she may need to tell your parent or a counselor or
another adult who can help. She would also need to tell an adult if you tell her that someone is
harming you. Everything else is private.
It is up to you whether you do the interview. If you agree to complete the interview, you will
receive $40 today.
You may think some of the questions are difficult. Some questions may make you feel certain ways,
such as sad. Remember that you do not have to answer any questions that you do not want to answer,
and you can stop the interview at any time. If you become upset at any time during the interview and
want to talk to a counselor about how you are feeling, the interviewer will give you toll-free hotline
numbers. These numbers are also printed on the payment receipt from your first interview.
If you have questions about the study, call 1-800-XXX-XXXX. If you have questions about your rights
as a study participant, call RTI’s Office of Research Protection at 1-866-214-2043 (a toll-free number).
You can also go to our project website: https://nmhsweb.rti.org/ for more information. Thank you for
your help.

Your confidentiality is protected by the Confidential Information Protection and Statistical Efficiency Act of 2002
(CIPSEA, PL 107-347). Any project staff or authorized data user who violates CIPSEA may be subject to a jail term of up
to 5 years, a fine of up to $250,000, or both.

NOTICE: Public reporting burden for this collection of information is estimated to average 60 minutes per response, 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, Paperwork Reduction Project (XXXX-XXXX); Room 15E57B; 5600 Fishers
Lane, Rockville, MD 20857. 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 XXXX-XXXX, expiration date XX/XX/XX.

Adult CRS Follow-up
U.S. Department of Health and
Human Services

Study Description

You have been randomly chosen for a special telephone follow-up study for the National Mental
Health Study. This study\is sponsored by the Substance Abuse and Mental Health Services
Administration (SAMHSA) and the National Institute of Mental Health (NIMH), both part of the U.S.
Department of Health and Human Services (DHHS). The study will involve your participation in a
second interview that includes additional questions about mental health and other health-related
topics. The interview will be conducted over the phone and takes on average an hour to complete.
If you agree to participate, we will ask for your name and telephone number. This information will
be used only to contact you for the telephone interview. While the interview has some personal
questions, federal law protects the privacy of your answers and requires us to keep all of your
answers confidential. Any data that you provide will only be used by authorized personnel for
statistical purposes according to the Confidential Information Protection and Statistical Efficiency
Act of 2002. The only exception to this promise of confidentiality is if you tell the interviewer that
you intend to seriously harm yourself or someone else; in this situation RTI may need to notify a
mental health professional or other authorities.
Your participation is voluntary. If you agree to complete the interview, you will receive $40
today.
You may consider some questions to be sensitive, and some questions also may make you feel
certain emotions, such as sadness. Remember that you can refuse to answer any questions that
you do not want to answer, and you can stop the interview at any time. If you become upset at
any time during the interview and wish to speak to a mental health professional about how you are
feeling, the interviewer can provide you with toll-free hotline numbers.
If you have questions about the study, call the Project Representative at 1-800-XXX-XXXX. If you
have questions about your rights as a study participant, call RTI’s Office of Research Protection at
1-866-214-2043 (a toll-free number). You can also visit our project Website:
https://www.nmhsweb.org for more information. Thank you for your cooperation and time.

Lisa J. Colpe, Ph.D., MPH
National Study Director, DHHS

Grace Medley

National Field Director, DHHS

Your confidentiality is protected by the Confidential Information Protection and Statistical Efficiency Act of 2002
(CIPSEA, PL 107-347). Any project staff or authorized data user who violates CIPSEA may be subject to a jail term
of up to 5 years, a fine of up to $250,000, or both.

CRS Recruitment Scripts
CRS Recruitment occurs at the end of the main interview. Recruitment instructions and
scripts will appear on the laptop if someone is selected for the CRS.
1. Adult CRS Recruitment Script in Main Interview (Age 18+)
You have been selected to participate in one additional study for the U.S. Department of
Health and Human Services. For this study, we are interested in interviewing a wide
variety of individuals to learn about how different people think and talk about feelings
and experiences. The interview will include additional questions about your mental
health and other health related issues. It will be conducted over the telephone and will
take about an hour. Participation in this interview is voluntary and all of your answers
will be kept confidential.
HAND ADULT FOLLOW-UP STUDY DESCRIPTION TO RESPONDENT. Please read
this statement. It describes the survey and how federal law keeps your answers private.
We hope that protecting your privacy will help you to give accurate answers.
If you agree to participate, I will pay you an additional $40 today. Within the next two
weeks, a different interviewer will call you to explain more about the interview and to
schedule a convenient time to complete it. If you wish, you may complete the full
interview when the interviewer calls.
IF ASKED “WHY WAS I SELECTED”: Anyone who participates in the National Mental
Health Study may be chosen for this special study. This study is sponsored by the
Substance Abuse and Mental Health Services Administration (SAMHSA), and the
National Institute of Mental Health (NIMH), both part of the U.S. Department of Health
and Human Services (DHHS). Knowledge gained from the study will improve our ability
to describe and understand mental health issues in the United States.
To accommodate your schedule, an interviewer will be available to call you about this
study and schedule a convenient time to complete the interview within the next four
weeks.
INDICATE YES OR NO IN COMPUTER TO INDICATE IF ADULT AGREES TO
PARTICIPATE IN CRS FOLLOW-UP INTERVIEW.
1
2
3

RESPONDENT AGREES TO RECONTACT
RESPONDENT DOES NOT AGREE TO RECONTACT
RESPONDENT IS NOT AVAILABLE DURING THE SPECIFIED TIME
PERIOD

[IF RESPONDENT AGREES TO CRS CONTINUE REMAINDER OF SCRIPT]

Since another interviewer will be completing the second interview, may I have your first
name and phone number so the interviewer can call you?
ENTER FIRST NAME ONLY AND PHONE NUMBER.
NAME

____________
ALLOW 20 CHARACTERS

PHONE

PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.
(IF NO CELL PHONE, TAP NEXT)
_____________
REF

[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF
NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT.
PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.]
DK/REF
ALLOW 10 CHARACTERS AND BLANKS

To check that I entered the number correctly, please repeat the phone number.
CONFIRM NUMBER. AS NEEDED, READ THE CONTACT INFORMATION ENTERED
TO THE RESPONDENT AND CONFIRM IT IS CORRECT.

Is there another number where the telephone interviewer could contact you about the
second interview?
IF YES: RECORD PHONE NUMBER AND TYPE (CELL, WORK, ETC) IN THE
NOTES FIELD. REPEAT ABOVE STEPS TO CONFIRM THE NUMBER. YOU MAY
ENTER UP TO 50 CHARACTERS.
IF NO: CONTINUE
PHONE2

PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.

_____________
REF

[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF
NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT.
2

PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.]
DK/REF
NOTES

_____________________________
ALLOW 30 CHARACTERS

PRESS [ENTER] TO CONTINUE.

Please also let me know the best days and times when you will be available in the next
two weeks. I will give this information to the interviewer, and he or she will try to contact
you during one of these times.
ENTER BEST DAYS/TIMES. AS NEEDED, PROBE FOR ADDITIONAL BEST
DAYS/TIMES.
READ THE INFORMATION ENTERED TO THE RESPONDENT AND CONFIRM IT IS
CORRECT.
COMPLETE A REMINDER CARD AND HAND TO THE RESPONDENT.
I have entered these days and times in the computer and recorded them on this card.
Please note the interviewer may try to reach you at other times as well.
INTERVIEWER NOTE: ADDITIONAL INFORMATION REGARDING THE BEST DAYS
OR TIMES PROVIDED BY THE RESPONDENT SHOULD BE ENTERED IN THE NOTES
FIELD. YOU MAY ENTER UP TO 50 CHARACTERS.
TELEPHONE INTERVIEWERS ARE AVAILABLE DAYS, EVENINGS AND
WEEKENDS.
PRESS [ENTER] TO CONTINUE.

BEST DAYS OF WEEK____________________________________
BEST TIMES OF DAY_____________________________________
NOTES

_____________________________________

ALLOW 50 CHARACTERS

HAND RESPONDENT $40 CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE INTERVIEW
INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP COPY TO
RESPONDENT.
3

I have signed this form to indicate that I have given you $40 for this interview. At the bottom of
this form, we have included national hotline numbers that you can call if you ever feel you need
to talk to someone about mental health or drug use issues.
Thank you in advance for your participation.

PRESS [ENTER] TO CONTINUE.

2. Adolescent CRS Recruitment Script in Main Interview (Age 13-17)
To Parent:
Your adolescent has been selected to participate in one additional study for the U.S.
Department of Health and Human Services. Are you the parent who has legal custody
of [ADOLESCENT] or are you this adolescent’s legal guardian?
[If not, interviewer should ask to speak to the parent or guardian who has legal
custody].
For this study, we are interested in interviewing a wide variety of individuals to learn
about how different adolescents think and talk about their feelings such as depression
or sadness, anxiety and fears, attention and concentration difficulties. The interview will
include questions about feelings and behaviors your adolescent may have experienced
including questions about self-harm. We will also ask questions about your
adolescent’s experience at home and school, including experiences with and exposure
to crime and violence.
Within the next two weeks, a different interviewer will call you to explain more about
your adolescent’s interview and to schedule a convenient time to complete it with your
adolescent. If you wish, your adolescent may complete the full interview when the
interviewer calls.
All of your adolescent’s answers will be confidential and used only for statistical
purposes. There are two exceptions to this promise of confidentiality. If your
adolescent tells the study interviewer that s/he intends to seriously harm him/herself or
someone else, s/he may need to notify you or a mental health professional or another
authority. If your adolescent tells the study interviewer that s/he is at risk of serious
harm by an adult, s/he may also need to notify you or another authority.
Your adolescent may consider some of the questions to be sensitive in nature and
some of the questions may also make your adolescent feel certain emotions, such as
sadness. Your adolescent can refuse to answer any questions that your s/he does not
want to answer, and your adolescent can stop the interview at any time. If your
adolescent becomes upset at any time during the interview and wishes to speak to a
mental health professional about how s/he is feeling, the study interviewer will provide
4

your adolescent with toll-free hotline numbers.
This interview will be conducted over the telephone and will take about an hour.
Participation in this interview is voluntary.
HAND PARENT/LEGAL GUARDIAN FOLLOW-UP STUDY DESCRIPTION TO
RESPONDENT. Please read this statement. It describes the survey and how federal
law keeps any information your adolescent provides private.
If you agree to allow your adolescent to participate, I will pay him/her an additional $40
today.
Do I have your permission to ask your adolescent to participate in this study?
INDICATE YES OR NO IN COMPUTER TO INDICATE IF PARENT/LEGAL GUARDIAN
PROVIDES PERMISSION TO TALK WITH ADOLESCENT

IF ASKED “WHY WAS MY ADOLESCENT SELECTED”: Anyone who participates in the
National Mental Health Study may be chosen for this special study. This study is
sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA), and the National Institute of Mental Health (NIMH), both part of the U.S.
Department of Health and Human Services (DHHS). Knowledge gained from the study
will improve our ability to describe and understand mental health issues in the United
States.)
To Adolescent:
You have been selected to participate in one additional study for the U.S. Department of
Health and Human Services. For this study, we are interested in interviewing a wide
variety of individuals to learn about how different individuals think and talk about
feelings and experiences. The interview will include questions about feelings and
behaviors you may have experienced during your life, including experiences with and
exposure to crime and violence. Your parent said that you can take part in this
interview if you want to. It is your choice whether you take part in this study. It will be
conducted over the telephone and will take about an hour.
HAND ADOLESCENT FOLLOW-UP STUDY DESCRIPTION TO RESPONDENT.
Please read this statement. It describes the survey and how federal law keeps your
answers private. We hope that protecting your privacy will help you to give accurate
answers.
If you agree to participate, I will pay you an additional $40 today. Within the next two
weeks, a different interviewer will call you to explain more about the interview and to
schedule a convenient time to complete it. If you wish, you may complete the full
interview when the interviewer calls.
IF ASKED “WHY WAS I SELECTED”: Anyone who participates in the National Mental
5

Health Study may be chosen for this special study. This study is sponsored by the
Substance Abuse and Mental Health Services Administration (SAMHSA), and
the National Institute of Mental Health (NIMH), both part of the U.S. Department of
Health and Human Services (DHHS). Knowledge gained from the study will improve
our ability to describe and understand mental health issues in the United States.
Do you want to participate in this additional study?
INDICATE YES OR NO IN COMPUTER TO INDICATE IF ADOLESCENT AGREES TO
PARTICIPATE IN CRS FOLLOW-UP INTERVIEW

IF YES: HAND ADOLESCENT RESPONDENT $40 CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE INTERVIEW
INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP COPY TO
RESPONDENT.
I have signed this form to indicate that I have given you $40 for this interview. At the
bottom of this form, we have included national hotline numbers that you can call if you
ever feel you need to talk to someone about mental health or drug use issues.
Thank you in advance for your participation.
PRESS [ENTER] TO CONTINUE.

IF ADOLESCENT AGREES TO PARTICIPATE, ASK TO SPEAK TO THE PARENT
AGAIN:
To accommodate your schedule, an interviewer will be available to call you and your
adolescent about this study and schedule a convenient time to complete the
adolescent’s interview within the next four weeks.

Since another interviewer will be completing the adolescent’s second interview, may I
have your first name and phone number so the interviewer can call you?
ENTER FIRST NAME ONLY AND PHONE NUMBER.
PARENT FIRST NAME ____________
ALLOW 20 CHARACTERS
CHILD FIRST NAME
____________
ALLOW 20 CHARACTERS
PARENT PHONE
NUMBER.

PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT

(IF NO CELL PHONE, TAP NEXT)
_____________
REF
[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF
NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH
RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR
“OK” TO CONTINUE.]
DK/REF
ALLOW 10 CHARACTERS AND BLANKS
To check that I entered the number correctly, please repeat the phone number.
CONFIRM NUMBER. AS NEEDED, READ THE CONTACT INFORMATION ENTERED
TO THE RESPONDENT AND CONFIRM IT IS CORRECT.

Is there another number where the telephone interviewer could contact you about the
adolescent’s second interview?
IF YES: RECORD PHONE NUMBER AND TYPE (CELL, WORK, ETC) IN THE
NOTES FIELD. REPEAT ABOVE STEPS TO CONFIRM THE NUMBER. YOU MAY
ENTER UP TO 50 CHARACTERS.
IF NO: CONTINUE
PHONE2

PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.

_____________
REF
[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF
NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH
RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR
“OK” TO CONTINUE.]
DK/REF
NOTES

_____________________________
ALLOW 30 CHARACTERS

PRESS [ENTER] TO CONTINUE.

Please also let me know the best days and times when you will be available in the next
two weeks. I will give this information to the interviewer, and he or she will try to contact
you during one of these times.
ENTER BEST DAYS/TIMES. AS NEEDED, PROBE FOR ADDITIONAL BEST
DAYS/TIMES.
READ THE INFORMATION ENTERED TO THE RESPONDENT AND CONFIRM IT IS
CORRECT.
COMPLETE A REMINDER CARD AND HAND TO THE RESPONDENT.
I have entered these days and times in the computer and recorded them on this card.
Please note the interviewer may try to reach you at other times as well.
INTERVIEWER NOTE: ADDITIONAL INFORMATION REGARDING THE BEST DAYS
OR TIMES PROVIDED BY THE RESPONDENT SHOULD BE ENTERED IN THE
NOTES FIELD. YOU MAY ENTER UP TO 50 CHARACTERS.
TELEPHONE INTERVIEWERS ARE AVAILABLE DAYS, EVENINGS AND
WEEKENDS.
PRESS [ENTER] TO CONTINUE.

BEST DAYS OF WEEK____________________________________
BEST TIMES OF DAY_____________________________________
NOTES

_____________________________________

ALLOW 50 CHARACTERS
PRESS [ENTER] TO CONTINUE.

3. Parent CRS Recruitment Script (for Parent CRS Interview): READ TO
PARENT/LEGAL GUARDIAN AFTER ADOLESCENT IS RECRUITED FOR CRS
You have been selected to participate in one additional study for the U.S. Department of
Health and Human Services. The interview will ask questions about mental health
issues your adolescent may have experienced including questions about their
depression or sadness, anxiety and fears, and attention and concentration difficulties.
The interview will also include questions about feelings and behaviors your adolescent
may have experienced including questions about self-harm. It will be conducted over
the telephone and will take about 30 minutes. Participation in this interview is voluntary
and all of your answers will be kept confidential.
HAND PARENT/LEGAL GUARDIAN FOLLOW-UP STUDY DESCRIPTION TO
RESPONDENT. Please read this statement. It describes the survey and how federal
law keeps your answers private. We hope that protecting your privacy will help you to
give accurate answers.
If you agree to participate, I will pay you an additional $30 today. Within the next two
weeks, a different interviewer will call you to explain more about the interview and to
schedule a convenient time to complete it. If you wish, you may complete the full
interview when the interviewer calls.
IF ASKED “WHY WAS I SELECTED”: Anyone who participates in the National Mental
Health Study may be chosen for this special study. Since your adolescent was selected
and has agreed to participate, you have the opportunity to participate in this additional
study as well. This study is sponsored by the Substance Abuse and Mental Health
Services Administration (SAMHSA), and the National Institute of Mental Health (NIMH),
both part of the U.S. Department of Health and Human Services (DHHS). Knowledge
gained from the study will improve our ability to describe and understand mental health
issues in the United States.

To accommodate your schedule, an interviewer will be available to call you about this
study and schedule a convenient time to complete the interview within the next four
weeks.
INDICATE YES OR NO IN COMPUTER TO INDICATE IF ADULT AGREES TO
PARTICIPATE IN CRS FOLLOW-UP INTERVIEW.
1
2

RESPONDENT AGREES TO RECONTACT
RESPONDENT DOES NOT AGREE TO RECONTACT
9

RESPONDENT IS NOT AVAILABLE DURING THE SPECIFIED TIME
PERIOD

[IF RESPONDENT AGREES TO CRS CONTINUE REMAINDER OF SCRIPT]
It is important to the study that you complete the main parent survey before you do the follow-up
study. Please try to complete the parent interview via the web or over the telephone within the
next week.

Since another interviewer will be completing the second interview, may I have your first
name and phone number so the interviewer can call you?
ENTER FIRST NAME ONLY AND PHONE NUMBER.
NAME

____________
ALLOW 20 CHARACTERS

PHONE

PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.
(IF NO CELL PHONE, TAP NEXT)
_____________
REF

To check that I entered the number correctly, please repeat the phone number.
CONFIRM NUMBER. AS NEEDED, READ THE CONTACT INFORMATION ENTERED
TO THE RESPONDENT AND CONFIRM IT IS CORRECT.

PLEASE ENTER 3 DIGIT AREA CODE AND 7 DIGIT NUMBER.

_____________
REF

[ALLOW 3+3+4 NUMERIC AND BLANKS AND CHECK AGAINST LOOKUP TABLE OF VALID AREA CODE. ADMINISTER A SOFT CHECK IF
NOT FOUND, “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT.
11

PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.]
DK/REF
NOTES

_____________________________
ALLOW 30 CHARACTERS

PRESS [ENTER] TO CONTINUE.

BEST DAYS OF WEEK____________________________________
BEST TIMES OF DAY_____________________________________
NOTES

_____________________________________

ALLOW 50 CHARACTERS

HAND RESPONDENT $30 CASH.
MARK THE APPROPRIATE “CASH ACCEPTANCE” BOX ON THE INTERVIEW
INCENTIVE RECEIPT.
SIGN AND DATE INTERVIEW INCENTIVE RECEIPT AND GIVE TOP COPY TO
RESPONDENT.
I have signed this form to indicate that I have given you $30 for this interview. At the bottom of
12

this form, we have included national hotline numbers that you can call if you ever feel you need
to talk to someone about mental health or drug use issues.
Thank you in advance for your participation.

PRESS [ENTER] TO CONTINUE.

CRS Confidential Notice

CONFIDENTIAL
INFORMATION
IF FOUND, PLEASE CONTACT
Suzanne Triplett
@ 1-800-334-8571
Ext. 26570
FEDEX TRACKING NUMBER: _______________________

Property of:
RTI International
3040 Cornwallis Road, Research Triangle Park, NC 27709
1-800-XXX-XXXX
1

National Mental Health Study Field Test,
Supporting Statement
Attachment N – Introduction and Consent for
the Clinical Interview

Introduction and Consent for the Clinical Interview
Adult
Before you place call, be prepared:
• Review the assignment information provided including the respondent name,
telephone number, as well as the date of the initial interview.
• Have your schedule available (in case you need to schedule an appointment).
• Have all interviewing materials available.
VERIFY NUMBER AND LOCATE RESPONDENT
Hi, my name is _______________ and I’m calling on behalf of the U.S. Department of
Health and Human Services. Is this [PHONE NUMBER]?
YES: PROCEED BELOW.
NO: I apologize. I need to double check my records. Thank you for your time. END
CALL.
I’m trying to reach [FIRST NAME] who agreed to take part in a telephone interview
we’re conducting. May I speak to [FIRST NAME]?
IF R NOT HOME OR UNAVAILABLE
When would be a good time to call again? ENTER CODE 52 AND DETAILS IN CMS.
Thank you for your time. END CALL.
IF R AVAILABLE
(Hi, my name is _______________.)
You recently completed an interview in your home with an interviewer working on the
National Mental Health Study.
Before I continue, can you confirm that you are not driving right now?
NOT DRIVING: PROCEED BELOW.
DRIVING: When would be a good time to call again? ENTER CODE XX AND
DETAILS IN CMS. Thank you for your time. END CALL.]
I am the interviewer you were told would contact you for a follow-up telephone interview.
Do you recall completing the first interview?
YES: PROCEED BELOW.
NO: VERIFY FIRST NAME OF PERSON YOU ARE SPEAKING TO.
1

IF NOT SPEAKING TO CORRECT RESPONDENT, ASK TO SPEAK TO
RESPONDENT.
IF NAME IS CORRECT AND RESPONDENT DOESN’T RECALL INITIAL INTERVIEW,
REMIND OF DATE OF INITIAL INTERVIEW.
IF CORRECT RESPONDENT STILL NOT FOUND: I apologize. I need to double
check my records. Thank you for your time. END CALL. ENTER CODE 59 AND
INVESTIGATE.

INFORMED CONSENT
Before we begin, I would like to remind you of the study details. This study, sponsored
by the U.S. Department of Health and Human Services, asks questions about various
mental health issues such as depression, anxiety, post-traumatic stress disorder, selfharm, substance dependence and exposure to violence. Although there is no benefit to
you personally, knowledge gained from this study will improve our ability to describe
and understand mental health issues in the United States. While the interview has
some personal questions, federal law keeps your answers private. The only exceptions
to this promise of confidentiality are if you tell me that you intend to seriously harm
yourself or someone else, or you or another person, including a child, is in danger. In
these situations, I may need to notify a mental health professional or other authorities.
Your participation is voluntary. You may consider some of the questions to be sensitive
in nature and some of the questions may also make you feel certain emotions, such as
sadness. Remember that you can refuse to answer any questions that you do not want
to answer, and you can stop the interview at any time. If you become upset at any time
during the interview and wish to speak to a mental health professional about how you
are feeling, I will provide you with the toll-free hotline numbers that are printed on your
payment receipt from the first interview. The interview will take about an hour.
These study details are also included on the Follow-up Study Description you received
from the interviewer who met with you in your home. Do you have any questions before
we begin? ANSWER ANY RESPONDENT QUESTIONS.
Is it OK to continue with the interview?
YES: PROCEED TO NEXT PAGE
NO: BASED ON CONVERSATION:
What sort of concerns do you have about participating?
OR
Are there other questions that I could answer for you?
IF R STILL UNWILLING TO PARTICIPATE: Thank you for your time. END CALL.

PRIVACY
Because you may not want others to hear the responses to some of our questions, I’d
like to be sure you’re in a private area. Where are you right now? Are you at home, at
work, or somewhere else? Are you in an area where you can answer these questions
privately?
YES: PROCEED
NO: Please consider moving to a more private area. Do you need more time?
YES: PAUSE, THEN CONTINUE
NO: CONTINUE
Is now a good time to complete this interview?
YES: PROCEED. BE SURE TO READ VERBATIM.
NO: When would be a good time to call again? ENTER CODE 50 AND DETAILS IN
CMS.
Thank you for your time. END CALL.
.
RECORDING PERMISSION
In order to ensure that I am conducting this interview accurately and properly, I would
like to make an electronic audio recording of this interview. This is done strictly for
quality control purposes. The recording will only be listened to by staff members on the
project who have signed confidentiality pledges. The recording will be stored in a
secure manner and will not contain your name—only a random number that will be
assigned to this case. To help maintain confidentiality, we ask that you not give your
name or any other identifying information, such as an address or place of business,
during the interview. All recordings will be permanently destroyed within eighteen
months after the end of the data collection period. You can still do the interview if you
do not want me to record it.
Do you agree to allow me to record the interview?
YES: I will now begin recording. START RECORDING AND SAY: “This is [YOUR
FIRST AND LAST NAME] conducting telephone interview [QUEST ID] on [DATE].”
NO: DON’T RECORD
Ok, let’s get started.

CRS Adolescent Interview
Parent Introduction/Permission Script and Adolescent Informed
Assent
Before you place call, be prepared:
• Review the assignment information provided including the adolescent respondent
and parent name, telephone number, as well as the date of the initial interview.
• Know for scheduling whether parent needs to be present when the adolescent is
completing the interview
• Have your schedule available (in case you need to schedule an appointment).
• Have all interviewing materials available.
• If both parent and adolescent to be interviewed, the parent must be scheduled and
completed before the adolescent.
VERIFY NUMBER AND LOCATE PARENT
Hi, my name is _______________ and I’m calling on behalf of the U.S. Department of
Health and Human Services. Is this [PHONE NUMBER]?
YES: PROCEED BELOW.
NO: I apologize. I need to double check my records. Thank you for your time. END
CALL.
Before I continue, can you confirm that you are not driving right now?
NOT DRIVING: PROCEED BELOW.
DRIVING: When would be a good time to call again? ENTER CODE XX AND DETAILS
IN CMS. Thank you for your time. END CALL.
I’m trying to reach [PARENT NAME] who agreed to allow [ADOLESCENT FIRST
NAME] to be contacted about taking part in a telephone interview we’re conducting.
Are you [PARENT NAME WHO GAVE CONSENT]?
NO: Is [FILL PARENT NAME WHO GAVE PERMISSION FOR ADOLESCENT TO BE
CONTACTED] available to speak with?
YES: PROCEED BELOW
NO: Is another parent/legal guardian of [ADOLESCENT FIRST NAME] available
to speak with?
YES: PROCEED BELOW
NO: ASK FOR A GOOD TIME TO CALL AGAIN WHEN [FILL PARENT
NAME WHO GAVE CONSENT] IS HOME. ENTER CODE 52 AND
DETAILS IN CMS.
4

YES: [IF TALKING TO ORIGINAL PARENT FILL: As you may recall / ELSE
CONTINUE], your adolescent has been selected to participate in one additional study
for the U.S. Department of Health and Human Services.
For this study, we are interested in interviewing a wide variety of individuals to learn
about how different adolescents think and talk about their feelings such as depression
or sadness, anxiety and fears, attention and concentration difficulties. The interview will
include questions about feelings and behaviors your adolescent may have experienced
including questions about self-harm. We will also ask questions about your
adolescent’s experience at home and school, including experiences with and exposure
to crime and violence.
All of your adolescent’s answers will be confidential and used only for statistical
purposes. There are two exceptions to this promise of confidentiality. If your
adolescent tells the study interviewer that s/he intends to seriously harm him/herself or
someone else, s/he may need to notify you or a mental health professional or another
authority. If your adolescent tells the study interviewer that s/he is at risk of serious
harm by an adult, s/he may also need to notify you or another authority.
Your adolescent may consider some of the questions to be sensitive in nature and
some of the questions may also make your adolescent feel certain emotions, such as
sadness. Your adolescent can refuse to answer any questions that your s/he does not
want to answer, and your adolescent can stop the interview at any time. If your
adolescent becomes upset at any time during the interview and wishes to speak to a
mental health professional about how s/he is feeling, the study interviewer will provide
your adolescent with toll-free hotline numbers.
The interview will take about an hour. Participation in this interview is voluntary.
This information about the study is also included on the Follow-up Study Description [IF
PARENT THAT GAVE ORIGINAL PERMISSION TO CONTACT THE ADOLESCENT
FILL: you were given by the interviewer who met with you in your home / ELSE FILL:
the other parent was given by the interviewer who met with him/her in your home]. Do
you have any questions before we begin? ANSWER ANY RESPONDENT
QUESTIONS.
Do I have your permission to interview your adolescent for this study?
YES: PROCEED BELOW
NO: Thank you for your time. END CALL

Thank you for giving us permission to interview your adolescent. It is [FILL
ADOLESCENT FIRST NAME’S] choice whether he or she wants take part in this study.
5

If your adolescent agrees to participate, I will work to set up a convenient time with
him/her to complete the follow-up interview. Will you want the interview to take place at
a time when you are home with the adolescent, or are you OK with my calling your
adolescent to complete this interview when you are not home?
PARENT WANTS TO BE AT HOME DURING ADOLESCENT INTERVIEW
PARENT INDICATES IT IS OK TO INTERVIEW ADOLESCENT IF PARENT
NOT HOME
MARK IN COMPUTER WHETHER PARENT/LEGAL GUARDIAN WANTS TO BE
PRESENT, OR IS OK WITH THE STUDY SPEAKING WITH THE ADOLESCENT
WHEN PARENT/LEGAL GUARDIAN IS NOT PRESENT.
May I speak to [ADOLESCENT FIRST NAME]?
IF R NOT HOME OR UNAVAILABLE
When would be a good time to call again? ENTER CODE 52 AND
DETAILS IN CMS.
Thank you for your time. END CALL.

IF R AVAILABLE
(Hi, my name is _______________.)
You recently completed an interview in your home with an interviewer working on the
National Mental Health Study. I am the interviewer you were told would contact you for
a follow-up telephone interview. Do you remember doing the first interview?
YES: PROCEED BELOW.
NO: VERIFY FIRST NAME OF PERSON YOU ARE SPEAKING TO.
IF NOT SPEAKING TO CORRECT RESPONDENT, ASK TO SPEAK TO
RESPONDENT.
IF NAME IS CORRECT AND RESPONDENT DOESN’T RECALL INITIAL INTERVIEW,
REMIND OF DATE OF INITIAL INTERVIEW.
IF CORRECT RESPONDENT STILL NOT FOUND: I apologize. I need to double
check my records. Thank you for your time. END CALL. ENTER CODE 59 AND
INVESTIGATE.
IF PARENT/LEGAL GUARDIAN WHO GAVE CONSENT WANTS TO BE AT HOME
WITH ADOLESCENT WHEN INTERVIEW TAKES PLACE, ASK: I need to confirm is
[FILL PARENT NAME WHO GAVE CONSENT] at home with you now?
YES: PROCEED
6

NO: GO TO ITEM ASKING FOR A GOOD TIME TO CALL AGAIN
Before I continue, can you confirm that you are not driving right now?
NOT DRIVING: PROCEED BELOW.
DRIVING: When would be a good time to call again? ENTER CODE XX AND DETAILS
IN CMS. Thank you for your time. END CALL.

INFORMED ASSENT
I would like to remind you of the study details. This study, sponsored by the U.S.
Department of Health and Human Services, asks questions about many mental health
issues like sadness, fear, and attention problems, as well as self-harm and experiences
with and exposure to crime and violence. There really is not a way you will get helped
directly from doing the study. But, information that we get from you and others your age
will help us understand mental health issues for teenagers across the country. The
interview does have some personal questions. But, by law, we’re required to keep your
answers private. This is true except for a couple of times. If you tell me that you plan to
seriously harm yourself or someone else, I may need to tell your parent or a counselor
or another adult who can help. I would also need to tell an adult if you tell me that
someone is harming you. Everything else is private. We hope that protecting your
privacy will help you to give truthful answers. You can quit the interview at any time.
You can also refuse to answer any questions. The interview will take about an hour.
It is your choice whether or not you do the interview. You may think some of the
questions are difficult, and some of the questions may make you feel certain ways, such
as sad. Remember that you do not have to answer any questions that you do not want
to answer, and you can stop the interview at any time. If you become upset at any time
during the interview and want to speak to a counselor about how you are feeling, I will
give you the toll-free hotline numbers that are printed on your payment receipt from the
first interview.
This information about the study is also included on the Follow-up Study Description
you were given by the interviewer who met with you in your home. Do you have any
questions before we begin? ANSWER ANY RESPONDENT QUESTIONS.
Is it OK to continue with the interview?
YES: PROCEED TO NEXT PAGE
NO: BASED ON CONVERSATION:
What sort of concerns do you have about participating?
OR
Are there other questions that I could answer for you?
IF R STILL UNWILLING TO PARTICIPATE: Thank you for your time. END CALL.
Is now a good time to complete this interview?
7

YES: PROCEED. BE SURE TO READ VERBATIM.
NO: When would be a good time to call again? ENTER CODE 50 AND DETAILS IN
CMS.
Thank you for your time. END CALL.
PRIVACY
Because you may not want others to hear the responses to some of our questions, I’d
like to be sure you’re at home and in a private area.
Are you at home and in a private place where you can safely talk on the phone and
answer my questions?
YES: PROCEED
IF NOT AT HOME: When is a good time for me to reach you at home ENTER CODE
50 AND DETAILS IN CMS. Thank you for your time. END CALL.
IF AT HOME BUT NOT IN A PRIVATE AREA:
Are you able to move to a place where you can safely talk?
YES: PAUSE, THEN CONTINUE
NO: CONTINUE
Be sure not to use your speaker phone for this interview. Keep the speaker phone off
for the interview. I want to make sure our conversation is private. Do you have your
speaker phone off?
YES: PROCEED

RECORDING PERMISSION
In order to make sure that I am doing my job correctly, I would like to make an electronic
audio recording of this interview. This is done only to make sure I am doing my job
correctly. The recording will only be listened to by people who work on the project who
have signed confidentiality pledges. A confidentiality pledge is a written promise that
information will not be shared with anyone. The recording will not include your name—
only a random number that will be given to this case. To help provide confidentiality, we
ask that you not give your name or any other identifying information, such as your
address during the interview. The recording will be will be destroyed within eighteen
months after the end of the project. You can still do the interview if you do not want me
to record it. Do you agree to allow me to record the interview?
YES: I will now begin recording. START RECORDING AND SAY: “This is [YOUR
FIRST AND LAST NAME] conducting telephone interview [QUEST ID] on [DATE].”
NO: DON’T RECORD
Ok, let’s get started.

CRS Parent Introduction Script and Informed Consent
Before you place call, be prepared:
• Review the assignment information provided including the parent respondent name,
adolescent name, telephone number, as well as the date of the initial interview.
• Have your schedule available (in case you need to schedule an appointment).
• Have all interviewing materials available.
VERIFY NUMBER AND LOCATE RESPONDENT
Hi, my name is _______________ and I’m calling on behalf of the U.S. Department of
Health and Human Services. Is this [PHONE NUMBER]?
YES: PROCEED BELOW.
NO: I apologize. I need to double check my records. Thank you for your time. END
CALL.
I’m trying to reach [FIRST NAME] who agreed to take part in a telephone interview
we’re conducting. May I speak to [FIRST NAME]?
IF R NOT HOME OR UNAVAILABLE
When would be a good time to call again? ENTER CODE 52 AND DETAILS IN CMS.
Thank you for your time. END CALL.
IF R AVAILABLE
(Hi, my name is _______________.)
You were recently asked to complete a National Mental Health Study interview online or
via telephone.
Have you already completed that interview? (IF NO STATE: It is not required that you
complete the initial interview before the interview we will do today, but we would like you
to please try to complete that parent interview via the web or over the telephone within
the next week.)
Before I continue, can you confirm that you are not driving right now?
NOT DRIVING: PROCEED BELOW.
DRIVING: When would be a good time to call again? ENTER CODE XX AND
DETAILS IN CMS. Thank you for your time. END CALL.]

I am the interviewer you were told would contact you for a follow-up telephone interview
about [FILL ADOLESCENT NAME]. Do you recall completing the first parent interview?
9

YES: PROCEED BELOW.
NO: VERIFY FIRST NAME OF PERSON YOU ARE SPEAKING TO.
IF NOT SPEAKING TO CORRECT RESPONDENT, ASK TO SPEAK TO
RESPONDENT.
IF NAME IS CORRECT AND RESPONDENT DOESN’T RECALL INITIAL INTERVIEW,
REMIND OF DATE OF INITIAL INTERVIEW.
IF CORRECT RESPONDENT STILL NOT FOUND: I apologize. I need to double
check my records. Thank you for your time. END CALL. ENTER CODE 59 AND
INVESTIGATE.

INFORMED CONSENT
Before we begin, I would like to remind you of the study details.
This study, sponsored by the U.S. Department of Health and Human Services, will ask
questions about mental health issues your adolescent may have experienced including
questions about their depression or sadness, anxiety and fears, and attention and
concentration difficulties. The interview will also include questions about feelings and
behaviors your adolescent may have experienced including questions about self-harm.
A parent’s perspective is very important in getting an accurate description of an
adolescent’s health and development. Since you are the parent who completed the
parent questionnaire we would like you to complete this parent follow-up interview as
well. It will be conducted over the telephone and will take about 30 minutes.
Participation in this interview is voluntary and all of your answers will be kept
confidential. The only exception to this promise of confidentiality is if you or another
person, including a child, is in danger. In these situations I may need to notify a mental
health professional or other authorities.
Although there is no benefit to you personally, knowledge gained from this study will
improve our ability to describe and understand mental health issues for adolescents in
the United States.
Your participation is voluntary. You may consider some of the questions to be sensitive
in nature and some of the questions may also make you feel certain emotions, such as
sadness. Remember that you can refuse to answer any questions that you do not want
to answer, and you can stop the interview at any time. If you become upset at any time
during the interview and wish to speak to a mental health professional about how you
are feeling, I will provide you with the toll-free hotline numbers that are printed on your
payment receipt from the first interview.
These study details are also included on the Parent Follow-up Study Description you
received from the interviewer who met with you in your home. Do you have any
10

questions before we begin? ANSWER ANY RESPONDENT QUESTIONS.
Is it OK to continue with the interview?
YES: PROCEED TO NEXT PAGE
NO: BASED ON CONVERSATION:
What sort of concerns do you have about participating?
OR
Are there other questions that I could answer for you?
IF R STILL UNWILLING TO PARTICIPATE: Thank you for your time. END CALL.

PRIVACY
Because you may not want others to hear the responses to some of our questions, I’d
like to be sure you’re in a private area. Where are you right now? Are you at home, at
work, or somewhere else? Are you in a place where you can safely talk on the phone
and answer my questions?
YES: PROCEED
NO: Are you able to move to a place where you can safely talk?
YES: PAUSE, THEN CONTINUE
NO: When would be a good time to call again? ENTER CODE 50 AND DETAILS IN
CMS. Thank you for your time. END CALL.
Is now a good time to complete this interview?
YES: PROCEED. BE SURE TO READ VERBATIM.
NO: When would be a good time to call again? ENTER CODE 50 AND DETAILS IN
CMS.
Thank you for your time. END CALL.

RECORDING PERMISSION
In order to ensure that I am conducting this interview accurately and properly, I would
like to make an electronic audio recording of this interview. This is done strictly for
quality control purposes. The recording will only be listened to by staff members on the
project who have signed confidentiality pledges. The recording will be stored in a
secure manner and will not contain your name—only a random number that will be
assigned to this case. To help maintain confidentiality, we ask that you not give your
name or any other identifying information, such as an address or place of business,
during the interview. All recordings will be permanently destroyed within eighteen
months after the end of the data collection period. You can still do the interview if you
do not want me to record it.
11

Do you agree to allow me to record the interview?
YES: I will now begin recording. START RECORDING AND SAY: “This is [YOUR
FIRST AND LAST NAME] conducting telephone interview [QUEST ID] on [DATE].”
NO: DON’T RECORD
Ok, let’s get started.

National Mental Health Study Field Test,
Supporting Statement
Attachment X – CRS Cover Sheet and
Transmittal Forms

CRS Cover Sheet
OMB#
Expiration Date:

SCID-RV for DSM-5®
Version 1.0.0
Overview Module
Michael B. First, M.D., Janet B. W. Williams, Ph.D.,
Rhonda S. Karg, Ph.D., Robert L. Spitzer, M.D.
Modified for the National Mental Health Study

Interviewer ID:

QUESTID:

Date of Interview:

NOTICE: Public reporting burden for this collection of information is estimated to average 60
minutes per response, 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, Paperwork Reduction Project (XXXX-XXXX); Room 15E57B; 5600 Fishers
Lane, Rockville, MD 20857. 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 XXXX-XXXX, expiration date XX/XX/XX.

Adult CRS Transmittal Form
Interviewer ID:

QuestID:
Date of Interview:

Date Shipped To RTI:

Date Received at RTI:

____/ _____/ _____
MM DD
YY

Clinical QC by:

Edited by:

____/ _____/ _____
MM DD
YY

Date of Clinical QC:

____/ _____/ _____
MM DD
YY

Date Edited:

____/ _____/ _____
MM DD
YY

Check the box next to each modules included In shipment
Overview
Mood Disorders
Panic Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
PTSD
Eating Disorders
Psychosis Screen
Borderline Personality Disorder Screen
End of Interview/Interviewer Debriefing
Cognitive Impairment Assessment
GMC/Substance Rule-out for mood disorders
GMC/Substance Rule-out for anxiety disorders

√

Adolescent/Parent CRS Transmittal Form
Interviewer ID:

QuestID:
Date of Interview:
____/ _____/ _____
MM DD
YY

Date Shipped To RTI:
Date Received at RTI:

____/ _____/ _____
MM DD
YY

Clinical QC by:

Edited by:

____/ _____/ _____
MM DD
YY

Date of Clinical QC:

____/ _____/ _____
MM DD
YY

Date Edited:

____/ _____/ _____
MM DD
YY

Check the box next to each modules included In shipment
Overview
Mood Disorders
Panic Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
PTSD
Eating Disorders
Psychosis Screen
ADHD
Conduct Disorder
End of Interview/Interviewer Debriefing
Cognitive Impairment Assessment

√

National Mental Health Study Field Test,
Supporting Statement
Attachment AE – Clinician Distressed
Respondent Protocol

Clinician Distressed Respondent Protocol Overview
The National Mental Health Study (NMHS) is a NSDUH-like field test that focuses
explicitly on the collection of specific mental disorder data. It is a field test to prepare for
a study that aims to produce national-level estimates on a broad range of mental
disorders.
The NMHS data collection will involve interviewing selected adults and/or adolescents in
the home with CAPI and ACASI technology. A majority of the adult and adolescent
questionnaires will be administered via ACASI (~85%). In addition, parents of
respondents aged 13-17 years old will be asked to complete a separate parent
questionnaire with questions about the respondent child online or via the telephone.
At the conclusion of the adult and adolescent main questionnaires, the system will
select a sample of respondents (both adolescents and adults) to participate in a
telephone-based Clinical Reappraisal Study (CRS) within 2-4 weeks of completing the
in-home interviews. As part of the adolescent clinical reappraisal effort, we will
interview parents as well.
During the telephone CRS study interview, a clinical interviewer may directly learn
through responses to the CRS interview questions that a respondent poses a serious
threat to his or her own safety or the safety of others. The CRS interviews pose
detailed questions about suicidal ideation, intent, plans and immediate risk of harm.
Consequently, it is essential that NMHS clinical interviewers be prepared to handle
these situations appropriately.
All NMHS interviewers will be instructed to be alert to signs of distress or agitation, or
indications of imminent danger of harm to oneself or another based on indirect and
direct statements made by respondents. In all such circumstances, the interviewers will
follow the appropriate distressed respondent protocol. The distressed respondent
protocol for non-clinical and clinical interviewers is outlined in the following sections.

Clinician Distressed Respondent Protocol
Due to the nature of the clinical interview questions asked during the NMHS Clinical
Reappraisal Study (CRS) telephone data collection, it is possible that a respondent will
indicate during the course of his or her interactions with you that he or she poses a
likely threat to his or her own safety or the safety of others. It is essential that NMHS
project staff members be prepared to handle these situations appropriately.
As a clinical interviewer, you must be alert to signs of respondent distress or agitation,
or indication of imminent danger of harm to oneself or another based on indirect and
direct statements made by respondents.
There are 4 situations in which you might need to use the Distressed Respondent
Protocol (DRS):
1. A suicidal adult respondent
2. A suicidal adolescent respondent
3. A distressed or upset (but not suicidal) adult or adolescent respondent
4. A case of current suspected child abuse or neglect
In all such circumstances, you must follow the protocol outlined in this document. Each
scenario has specific steps to follow.
Situation 1: Suicidal Adult Respondent
If adult respondents report any of the issues listed below during any interactions with
you, including before, during, or after a screening or interview, you must follow the
instructions in the box provided. Details of all incidents must be documented in the
case management system and reported to your clinical supervisor immediately.


Has had any suicidal thoughts, including
– current and serious passive suicidal thoughts (i.e. thoughts or wishes
about his or her death in the absence of thoughts about specific ways he or
she could die or attempt suicide, plans for how he or she could die or attempt
suicide, or intention of dying or attempting suicide) [SCENARIO 1] or
– current and serious active suicidal thoughts (i.e. thoughts or wishes about
his or her death combined with thoughts about specific ways he or she
could die or attempt suicide, plans for how he or she could die or attempt
suicide, the intention of dying or attempting suicide, and the means to carry
out that plan [SCENARIO 2]

Follow the specific steps for each scenario below.

Clinician Distressed Respondent Protocol (Cont’d)
Scenario Number
1—Suicidal Adult
Respondent

Script for:
Current and Serious Passive Suicidal Thoughts

STEPS
1. COMPLETE SCREENING/INTERVIEW AND THEN READ TO R: When you agreed
to participate in this interview, I promised that I would not tell anyone what you have
told me unless it was necessary to protect you or other people. You told me earlier
that you have recently had thoughts or wishes about your death or dying.
2. Do you have a doctor, counselor, or someone you can talk to about how you are
feeling now?
IF YES: I strongly suggest that you contact this person immediately so you can talk
to him or her about how you have been feeling, especially about the thoughts you’ve
been having about death and dying. Would you be willing to do that?
IF YES: Okay. There is also a national hotline number you can call where
counselors are available to talk at any time of the day or night. Their toll-free
number is 1-800-273-8255. THANK R FOR THEIR PARTICIPATION IN THE
STUDY AND END CALL.
IF NO: I strongly suggest that you contact the national hotline number at 1-800-2738255. Counselors are available 24 hours a day to talk to you about how you are
feeling. They may also help you locate mental health services in your area. If you feel
that this is an emergency now or later, you should go to a hospital emergency room
right away. If you are not able to get to an emergency room immediately, you should
call 911 for assistance. THANK R FOR THEIR PARTICIPATION IN THE STUDY
AND END CALL.
3. WHEN CALL IS COMPLETED, CALL DR. BATTS OR DR. STAMBAUGH IF YOU

HAVE QUESTIONS OR WOULD LIKE TO DEBRIEF. FILL OUT A DISTRESSED
RESPONDENT REPORT AND E-MAIL YOUR CLINICAL SUPERVISOR.
EXCLUDE PERSONALLY IDENTIFYING INFORMATION (PII).

Clinician Distressed Respondent Protocol (Cont’d)
Scenario Number
2—Suicidal Adult
Respondent

Script for:
Current and Serious Active Suicidal Thoughts

STEPS
1. END SCREENING/INTERVIEW AND THEN READ TO R: When you agreed to
participate in this interview, I promised that I would not tell anyone what you have
told me unless it was necessary to protect you or other people. You told me earlier
that you are thinking about harming yourself. So, I would like to connect you with a
helpline where counselors are available to speak with you. Please stay on the line
while I call. If we get disconnected, I will call you back.
2. PUT RESPONDENT ON HOLD AND CALL National Suicide Prevention Lifeline
services TO SET UP A 3-WAY CALL: 1-800-273-TALK or 1-800-273-8255


IF SOMETHING HAPPENS AND YOU ARE UNABLE TO CONNECT TO
HELPLINE: KEEP THE RESPONDENT ON THE PHONE (ON HOLD) AND
CALL YOUR CLINICAL SUPERVISOR.

3. ONCE YOU REACH THE HELPLINE, READ: I work for RTI International, a
research organization in North Carolina, and we are conducting a research study.
During a telephone interview, a respondent told me that (he/she) is seriously thinking
about hurting (himself/herself). Even though I’m calling you from [FILL STATE], the
respondent lives in [INSERT SUBJECT’S STATE]. I have asked the respondent to
wait on the line while I contacted you. I can give you additional information about the
research study, if you would like. I can also provide you with the respondent’s
contact information. Remember that (he/she) should still be waiting on the other line.
DO NOT SHARE ANY INTERVIEW DATA.


well-being, I would report that to someone else who could help or intervene. Do you
have any questions about the study? ANSWER QUESTIONS. DO NOT SHARE
ANY INTERVIEW DATA.
4. INTERVIEWER ACTION: CONNECT RESPONDENT AND INTRODUCE TO THE
HELPLINE COUNSELOR. STAY ON THE LINE WHILE THE RESPONDENT
TALKS WITH THE HELPLINE COUNSELOR; IF YOU HANG-UP, THEIR
CONNECTION WILL ALSO END. IF THE RESPONDENT GETS DISCONNECTED
AND YOU CANNOT REACH HIM/HER ON THE PHONE AGAIN IMMEDIATELY,
CALL THE HELPLINE AND PROVIDE INFORMATION--GIVE RESPONDENT
NAME, TELEPHONE NUMBER, AND ADDRESS.
5. INTERVIEWER ACTION: WHEN CALL IS COMPLETED, CALL CLINICAL
SUPERVISOR. IF HE/SHE DOES NOT RETURN CALL WITHIN 15 MINUTES,
CALL DR. BATTS OR DR. STAMBAUGH TO DEBRIEF. IF NEITHER ONE OF
THEM IS AVAILABLE, CONTACT MS. TRIPLETT OR MR. MIERZWA TO NOTIFY
ONE OF THEM ABOUT THE INCIDENT. FILL OUT A DISTRESSED
RESPONDENT REPORT FORM AND E-MAIL YOUR CLINICAL SUPERVISOR.
EXCLUDE PII.


IF SOMETHING HAPPENS AND YOU ARE UNABLE TO CONNECT TO
HELPLINE OR R HANGS UP BEFORE YOU CONNECT R WITH LIFELINE AND
YOU CANNOT REACH R AGAIN.
CALL CLINICAL SUPERVISOR. SHE WILL SEARCH FOR THE LOCAL 911
NUMBER FOR THAT CHILD’S PART OF THE COUNTRY. SHE WILL CALL 911
AND GIVE THE RESPONDENT’S CONTACT INFORMATION.

Clinician Distressed Respondent Protocol (Cont’d)
Situation 2: Suicidal Adolescent Respondent
If an adolescent respondent reports any of the issues listed below during any
interactions with you, including before, during, or after a screening or interview, you
must follow the instructions in the box provided. Details of all incidents must be
documented in the case management system and reported to your clinical supervisor
immediately.


Has had any suicidal thoughts in the past two weeks, including
– current and serious passive suicidal thoughts (i.e. thoughts or wishes
about his or her death in the absence of thoughts about specific ways he or
she could die or attempt suicide, plans for how he or she could die or attempt
suicide, or intention of dying or attempting suicide) or
– current and serious active suicidal thoughts (i.e. thoughts or wishes
about his or her death combined with thoughts about specific ways he or she
could die or attempt suicide, plans for how he or she could die or attempt
suicide, the intention of dying or attempting suicide, and the means to carry
out that plan)

An adolescent with current and serious suicidal thoughts requires that you take action.
Follow the appropriate steps for the scenarios below. These scenarios require that you
set up a 3-way call with a parent or a national helpline to make sure that the child will be
safe when you finish the interview. We expect that you will almost always be able to
reach either the parent or the helpline. However, in an emergency, please do the
following:


IF SOMETHING HAPPENS AND YOU ARE UNABLE TO CONNECT TO THE
PARENT OR TO EITHER HELPLINE: KEEP THE CHILD RESPONDENT ON
THE PHONE (ON HOLD) AND CALL YOUR CLINICAL SUPERVISOR.



IF SOMETHING HAPPENS AND YOU ARE UNABLE TO CONNECT TO THE
PARENT OR CONNECT TO EITHER HELPLINE AND YOU ARE SERIOUSLY
CONCERNED THAT THE CHILD IS IN IMMEDIATE DANGER, CALL YOUR
CLINICAL SUPERVISOR. SHE WILL SEARCH FOR THE LOCAL 911
NUMBER FOR THAT CHILD’S PART OF THE COUNTRY. SHE WILL CALL
911 AND GIVE THE CHILD’S CONTACT INFORMATION.

Clinician Distressed Respondent Protocol (Cont’d)
Scenario Number
3—Suicidal Child
Respondent

Script for:
INFORMING CHILD RESPONDENT OF NEED TO
CONTACT PARENT

STEPS
1. INTERVIEWER READS: I promised that I would need to contact someone else only
if you were in danger of getting seriously hurt. What you have told me about hurting
yourself has me concerned about your safety and well-being. So, first I would like
you to write down a phone number where there is always an adult to talk to about
how you are feeling 24-hours a day. They can also help you find a counselor in your
area. Do you have a pen or pencil? (WAIT ON RESPONDENT) To contact the
national helpline, call 1-800-448-3000. Could you repeat that number back to me?
(IF RESPONDENT CANNOT REPEAT, READ THE TELEPHONE NUMBER
AGAIN). If you feel that this is an emergency now or later, you should tell an adult,
go to a hospital emergency room, or call 911 for help.
2. INTERVIEWER READS: Now, I would like to share what you told me with one of
your parents so they can make sure that you are safe. I will also have to tell my
supervisor. Would you like to stay on the phone when I talk to your parent about
this?
3. INTERVIEWER READS: Is your parent home? Can you go get him or her to join
our call? CHILD RESPONDENT MAY PASS PHONE DIRECTLY TO PARENT OR
REMAIN ON ONE LINE WHILE THE PARENT GETS ON ANOTHER. PARENT
MAY JOIN WITH OR WITHOUT THE ADOLESCENT ON THE LINE.
4. IF THE PARENT IS NOT HOME OR NOT NEAR THE CHILD, INTERVIEWER
READS: What is the best number to reach your parent right now?
5. ATTEMPT A 3-WAY CALL TO REACH THE PARENT.
6. IF THE RESPONDENT GETS EXTREMELY ALARMED AT THE IDEA OF YOU
TALKING TO THE PARENT, YOU SHOULD LINK THE ADOLESCENT DIRECTLY
TO A HELPLINE VIA A 3-WAY CALL. THIS SHOULD BE A RARE EVENT. SEE
SCENARIO 5 BELOW.

Clinician Distressed Respondent Protocol (Cont’d)
Scenario Number
4—Suicidal Child
Respondent

Script for:
PARENT CAN BE REACHED RIGHT AWAY

STEPS
1.

TO PARENT—INTERVIEWER READS: Your teenager was just completing his/her
interview for the NMHS Study. During that interview, your teenager told me that
he/she is currently having serious thoughts about harming him/herself, and we want
to make sure he/she is safe. I am not acting in a clinical capacity so I cannot tell you
more about what this means. However, I would like to let you know so that you can
talk to your teenager and decide what to do. You may want to contact your
teenager’s doctor or health care professional to discuss this further or call a local
behavioral health professional. I have a helpline number where counselors are
available 24 hours a day to speak with you or your teenager. They may also help
you find a counselor in your area. Do you have something to write with? (WAIT ON
RESPONDENT) The national helpline number is 1-800-448-3000. If you feel that
this is an emergency now or later, please take your teenager to a hospital
emergency room or call 911 for help.

RESPONDENT CLOSING SCRIPT (FOR EITHER THE PARENT REMAINING ON
THE LINE OR BOTH PARENT AND TEEN, IF TEEN HAS REMAINED): Thank
you for your time today. Good-bye.

INTERVIEWER ACTION: WHEN CALL IS COMPLETED, CALL YOUR CLINICAL
SUPERVISOR. IF SHE DOES NOT RETURN CALL WITHIN 15 MINUTES, CALL
DR. BATTS OR DR. STAMBAUGH TO DEBRIEF. IF NEITHER ONE OF THEM IS
AVAILABLE, CONTACT MS. TRIPLETT OR MR. MIERZWA TO NOTIFY ONE OF
THEM ABOUT THE INCIDENT. FILL OUT A DISTRESSED RESPONDENT
REPORT FORM AND E-MAIL YOUR CLINICAL SUPERVISOR. EXCLUDE PII.

Clinician Distressed Respondent Protocol (Cont’d)
Scenario Number
5—Suicidal Child
Respondent

Script for:
PARENT NOT HOME: LEAVING A MESSAGE AND
CONTACTING HELPLINE

STEPS
1. IF PARENT IS NOT HOME—INTERVIEWER LEAVES A MESSAGE: Hello, this is
[insert your name] calling from RTI International. I have just conducted the NMHS
interview with [insert child respondent’s name]. I would like to speak with you as
soon as possible about this interview. Please call Dr. Leyla Stambaugh at RTI
International as soon as you get a chance. Her number is 1-800-334-8571 extension
2-2618. We will attempt to call you back if we do not hear from you soon. Thank you.
2. IF PARENT IS NOT HOME AND THERE IS NO ALTERNATIVE PHONE NUMBER—
RETURN TO TEENAGER ON THE PHONE AND READ: I was not able to reach your parent
and I left a message for him/her to call RTI. Since I can’t reach your parent, I still want to
make sure that you are safe. I would like for you to be able to talk to another adult about how
you are feeling. So, I would like to connect you with a helpline where counselors are available
to speak with you. Please stay on the line while I call. If we get disconnected, I will call you
back.

PUT CHILD RESPONDENT ON HOLD AND CALL BOY’S TOWN NATIONAL
HELPLINE TO SET UP A 3-WAY CALL: 1-800-448-3000.
IF YOU CANNOT GET THROUGH USING THE BOYS TOWN NATIONAL HOTLNE,
CALL THE LIFELINE HELPLINE: 1-800-273-8255
3. ONCE YOU REACH THE HELPLINE, INTERVIEWER READS: I work for RTI
International, a research organization in North Carolina, and we are conducting a
research study. During a telephone interview, an adolescent respondent told me that
(he/she) is seriously thinking about hurting (himself/herself). Even though I’m calling
you from [FILL STATE], the respondent lives in [INSERT CHILD’S STATE]. I have
asked the respondent to wait on the line while I contacted you. I can give you
additional information about the research study, if you would like. I can also provide
you with the respondent’s contact information. Remember that (he/she) should still be
waiting on the other line.
DO NOT SHARE ANY INTERVIEW DATA.

IF ASKED FOR NMHS OVERVIEW: This study is sponsored by the U.S Department
of Health and Human Services. Knowledge gained from the study will improve our
ability to describe and understand mental health issues in the United States.
Questions ask about a variety of mental health issues that young people may face,
such as depression or sadness, anxiety and fears, attention and concentration
difficulties, and other health related issues, such as treatment and healthcare
experiences. Please note that this information was obtained through the respondent’s
participation in a research study. We went through appropriate informed consent
procedures, during which I told the respondent that if (he/she) told me something that
caused me to be concerned about (his/her) well-being, I would report that to someone
else who could help or intervene. Do you have any questions about the study?
ANSWER QUESTIONS. DO NOT SHARE ANY INTERVIEW DATA.
4. INTERVIEWER ACTION: CONNECT CHILD RESPONDENT AND INTRODUCE TO
THE HELPLINE COUNSELOR. STAY ON THE LINE WHILE THE CHILD
RESPONDENT TALKS WITH THE HELPLINE COUNSELOR; IF YOU HANG-UP,
THEIR CONNECTION WILL ALSO END. IF THE CHILD RESPONDENT GETS
DISCONNECTED AND YOU CANNOT REACH HIM/HER ON THE PHONE AGAIN
IMMEDIATELY, CALL THE HELPLINE AND PROVIDE INFORMATION--GIVE
CHILD RESPONDENT NAME, TELEPHONE NUMBER, AND ADDRESS.
5. INTERVIEWER ACTION: WHEN CALL IS COMPLETED, CALL YOUR CLINICAL
SUPERVISOR. IF SHE DOES NOT RETURN CALL WITHIN 15 MINUTES, CALL
DR. BATTS OR DR. STAMBAUGH TO DEBRIEF. IF NEITHER ONE OF THEM IS
AVAILABLE, CONTACT MS. TRIPLETT OR MR. MIERZWA TO NOTIFY ONE OF
THEM ABOUT THE INCIDENT. FILL OUT A DISTRESSED REPONDENT REPORT
FORM AND E-MAIL YOUR CLINICAL SUPERVISOR. EXCLUDE PII.
Protocol note: In cases where a message has been left for the parent, Dr. Batts or Dr.
Stambaugh will attempt to contact the parent within the next 24 hours and follow the previous
“parent information” script. When no message can be left for the parent, Dr. Batts or Dr.
Stambaugh will attempt to call the parent post-child interview reading the parent script from
this protocol.

Clinician Distressed Respondent Protocol (Cont’d)
Scenario Number
6—Suicidal Child
Respondent

Script for:
CHILD RESPONDENT IS ALARMED AND
ABSOLUTELY REFUSES PARENT CONTACT

STEPS
1. INTERVIEWER READS: I understand that you do not want me to contact your
parent. But, I must make sure that you are safe and I would like for you to be able to
talk to another adult about how you are feeling. So, I would like to connect you with a
helpline where counselors are available to speak with you. Please stay on the line
while I call. If we get disconnected, I will call you back.
2. INTERVIEWER ACTION: PUT CHILD RESPONDENT ON HOLD AND CALL THE
BOYS TOWN NATIONAL HELPLINE TO SET UP A 3-WAY CALL: 1-800-448-3000.
IF YOU CANNOT GET THROUGH USING THE BOYS TOWN HELPLINE, CALL
THE LIFELINE HELPLINE: 1-800-273-8255
3. ONCE YOU REACH THE HELPLINE, INTERVIEWER READS: I work for RTI
International, a research organization in North Carolina, and we are conducting a
research study. During a telephone interview, an adolescent respondent told me that
(he/she) is seriously thinking about hurting (himself/herself). Even though I’m calling
you from [FILL STATE], the respondent lives in [INSERT CHILD’S STATE]. I have
asked the respondent to wait on the line while I contacted you. I can give you
additional information about the research study, if you would like. I can also provide
you with the respondent’s contact information. Remember that (he/she) should still be
waiting on the other line.
DO NOT SHARE ANY INTERVIEW DATA.
IF ASKED FOR NMHS OVERVIEW: This study is sponsored by the U.S Department
of Health and Human Services. Knowledge gained from the study will improve our
ability to describe and understand mental health issues in the United States.
Questions ask about a variety of mental health issues that young people may face,
such as depression or sadness, anxiety and fears, attention and concentration
difficulties, and other health related issues, such as treatment and healthcare
experiences. Please note that this information was obtained through the respondent’s
11

participation in a research study. We went through appropriate informed consent
procedures, during which I told the respondent that if (he/she) told me something that
caused me to be concerned about (his/her) well-being, I would report that to someone
else who could help or intervene. Do you have any questions about the study?
ANSWER QUESTIONS. DO NOT SHARE ANY INTERVIEW DATA.
4. INTERVIEWER ACTION: CONNECT CHILD RESPONDENT AND INTRODUCE
HIM/HER TO THE HELPLINE COUNSELOR. STAY ON THE LINE WHILE THE
CHILD RESPONDENT TALKS WITH THE HELPLINE COUNSELOR; IF YOU
HANG-UP, THEIR CONNECTION WILL ALSO END. IF R DISCONNECTED AND
YOU CANNOT REACH HIM/HER ON THE PHONE AGAIN IMMEDIATELY, CALL
HELPLINE AND PROVIDE INFORMATION--GIVE CHILD RESPONDENT NAME,
TELEPHONE NUMBER, AND ADDRESS.
5. INTERVIEWER ACTION: WHEN CALL IS COMPLETED, CALL YOUR CLINICAL
SUPERVISOR. IF SHE DOES NOT RETURN CALL WITHIN 15 MINUTES, CALL DR.
BATTS OR DR. STAMBAUGH TO DEBRIEF. IF NEITHER ONE OF THEM IS AVAILABLE,
CONTACT MS. TRIPLETT OR MR. MIERZWA TO NOTIFY ONE OF THEM ABOUT THE
INCIDENT. FILL OUT DISTRESSED REPONDENT REPORT FORM AND E-MAIL YOUR

CLINICAL SUPERVISOR. EXCLUDE PII.

Clinician Distressed Respondent Protocol (Cont’d)
Situation 3: A distressed or upset (but not suicidal) adult or adolescent
respondent
If a respondent becomes distressed or upset (but not suicidal) during any interactions
with the recruiter or clinical interviewer, including before, during, or after a screening or
interview, the staff member will follow the instructions in the box provided below.
Scenario Number
7—Upset respondent

Script for:
RESPONDENT SEEMS UPSET BY THE INTERVIEW

STEPS
1. INTERVIEWER READS: Some of these questions are hard to talk about, and it
seems to be upsetting you.
INTERVIEWER ACTION: Offer the respondent a short break by saying:
“I realize these questions can be difficult to answer. Would you like to take a break and
get a drink of water?”
Depending on how the respondent answers you may do the following:
A. YES - CONTINUE WITH SENSITIVITY
Maybe you can call someone (FOR CHILD [like an adult that you trust]) when you get
off the phone so that she or he can help you talk about how you are feeling. Also, I
have a telephone number where counselors are available 24-hours a day to talk to
you about how you are feeling. Do you have a pen or pencil? (WAIT ON
RESPONDENT) To contact the national helpline, call [1-800-448-3000 for
adolescents / 1-800-273-8255 for adults]. Could you repeat that number back to
me? (IF RESPONDENT CANNOT REPEAT, READ THE TELEPHONE NUMBER
AGAIN)
INTERVIEWER ACTION: CONTINUE WITH INTERVIEW, IF POSSIBLE. AFTER
THE INTERVIEW, COMPLETE AND E-MAIL A DISTRESSED RESPONDENT
REPORT WITH YOUR CLINICAL SUPERVISOR INFORMING HIM OR HER A
TOLL-FREE NUMBER REFERRAL WAS GIVEN, RESPONDENT’S CASE ID,
INTERVIEWER’S ID, DATE, TIME, DETAILED DESCRIPTION OF THE

INTERACTION BETWEEN THE INTERVIEWER AND THE RESPONDENT, AND IF
THE APPROPRIATE PROTOCOLS WERE FOLLOWED. EXCLUDE PII.
B. YES, AND WOULD LIKE TO STOP INTERVIEW - Suspend and schedule another
interview time. State the following:
Maybe you can call someone (FOR CHILD [like an adult that you trust]) when you get
off the phone so that she or he can help you talk about how you are feeling. Also, I
have a telephone number where counselors are available 24-hours a day to talk to
you about how you are feeling. Do you have a pen or pencil? (WAIT ON
RESPONDENT) To contact the national helpline, call [1-800-448-3000 for
adolescents / 1-800-273-8255 for adults]. Could you repeat that number back to
me? (IF RESPONDENT CANNOT REPEAT, READ THE TELEPHONE NUMBER
AGAIN)
INTERVIEWER ACTION: COMPLETE AND FILE A DISTRESSED RESPONDENT
REPORT WITH YOUR CLINICAL SUPERVISOR INFORMING HIM OR HER A
TOLL-FREE NUMBER REFERRAL WAS GIVEN, RESPONDENT’S CASE ID,
INTERVIEWER’S ID, DATE, TIME, DETAILED DESCRIPTION OF THE
INTERACTION BETWEEN THE INTERVIEWER AND THE RESPONDENT, AND IF
THE APPROPRIATE PROTOCOLS WERE FOLLOWED.
C. NO, DON’T WANT TO CONTINUE EVER – Terminate the interview, thank the
respondent, and provide the incentive payment and receipt.
COMPLETE AND FILE A DISTRESSED RESPONDENT REPORT WITH YOUR
CLINICAL SUPERVISOR INFORMING HIM OR HER A TOLL-FREE NUMBER
REFERRAL WAS GIVEN, RESPONDENT’S CASE ID, INTERVIEWER’S ID, DATE,
TIME, DETAILED DESCRIPTION OF THE INTERACTION BETWEEN THE
INTERVIEWER AND THE RESPONDENT, AND IF THE APPROPRIATE
PROTOCOLS WERE FOLLOWED.

Clinician Distressed Respondent Protocol (Cont’d)
Situation 4: A case of present/current suspected child abuse or neglect
If during the adult or child interview the respondent shares information that leads you to
believe that a child is being been abuse or neglected, the staff member will follow the
instructions in the box provided below.
Scenario Number
8—Suspected child abuse or
neglect

Script for:
NO SCRIPT, ONLY INTERVIEWER ACTIONS
POST-INTERVIEW

STEPS

IF DURING THE COURSE OF THE ADULT OR CHILD INTERVIEW THE RESPONDENT
SHARES INFORMATION THAT LEADS YOU TO BELIEVE THAT A CHILD IS CURRENTLY
BEING ABUSED OR NEGLECTED.
1. INTERVIEWER ACTION: CONTINUE WITH INTERVIEW AND DO NOT BREAK
OFF. DO NOT ASK FOR ADDITIONAL DETAILS ABOUT THE SUSPECTED CHILD
ABUSE OR NEGLECT OR FOR ANY DETAILS BEYOND WHAT IS SHARED
NATURALLY DURING THE COURSE OF THE INTERVIEW. ONCE THE
INTERVIEW HAS BEEN COMPLETED, COMPLETE AND E-MAIL A DISTRESSED
RESPONDENT REPORT FORM WITH YOUR CLINICAL SUPERVISOR. WRITE
DOWN SPECIFICALLY WHAT THE RESPONDENT TOLD YOU THAT LED YOU TO
SUSPECT CHILD ABUSE OR NEGLECT. EXCLUDE PII.
2. CALL DR. BATTS OR DR. STAMBAUGH TO DEBRIEF. IF NEITHER ONE OF
THEM IS AVAILABLE, CONTACT MS. TRIPLETT OR MR. MIERZWA TO NOTIFY
ONE OF THEM THAT YOU HAVE A CASE OF SUSPECTED CHILD ABUSE OR
NEGLECT.

National Mental Health Study Field Test,
Supporting Statement
Attachment AG – CRS Unable-to-Contact
Letter

CRS Unable To Contact Letter
DATE
Resident
Attention: «R_FIRST_NAME»
«STREET_ADDRESS»
«CITY», «STATE» «ZIP»
Dear «R_FIRST_NAME1»:
Thank you for your recent participation in the National Mental Health Study (NMHS), a study being
conducted by Research Triangle Institute for the U.S. Department of Health and Human Services (DHHS).
When you completed the initial NMHS interview with one of our field interviewers, you agreed to
participate in a follow-up interview conducted over the telephone. However, since that time we have
been unable to contact you by telephone to complete this follow-up interview. Your participation in
this study is extremely important as only a limited number of people were selected to take part—this
is why we continue to try to reach you.
The interview will take approximately one hour and can be scheduled at a time that is convenient for
you within the next few days. To schedule your follow-up interview appointment, we ask that you
please contact «DCM», NMHS data collection manager, immediately upon receipt of this letter. You
may call «MS_LAST_NAME» toll free, 24 hours a day at «PHONE_NUMBER». If «MS_LAST_NAME» is
not available to take your call, please leave your first name, telephone number, address including city
and state, and the time you wish to be interviewed. When leaving a message, please state your
telephone number, including area code, clearly and repeat the number once to be sure we capture the
number correctly. «MS_LAST_NAME1» will call you back within 24 hours to confirm your appointment.
We appreciate that your time is a precious commodity. This is why our field interviewer provided an
additional [IF ADULT OR ADOLESCENT FILL $40; IF PARENT FILL $30] cash payment for agreeing to
participate in the follow-up interview as a token of appreciation for your time.
We are happy to work around your schedule in order to complete this very important research. Your
call to «MS_LAST_NAME2» is very important to the success of this study. Thank you for your assistance
with this important research effort.

Sincerely,

Amy Kowalski
National Field Director, RTI
*The National Mental Health Study is conducted by Research Triangle Institute for the Substance Abuse
and Mental Health Services Administration and the National Institute of Mental Health, both part of the
Department of Health and Human Services. [http://www.samhsa.gov] [http://www.nimh.gov]
[http://www.rti.org]

File Type	application/pdf
Author	gmchenry
File Modified	2017-04-13
File Created	2017-04-13