Survey/Interview Consent Forms

Survey Consent Information Sheet

Administrators

Your community mental health center (CMHC) has been randomly selected for participation in a study funded by the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) and conducted by Abt Associates. Through this study, we aim to better understand the capabilities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services.

As a part of this study, we are conducting a survey of CMHC administrators. Your participation in this survey will help the CDC better understand the capacity of CMHCs to provide cancer prevention services and the needs of CMHCs for training and resources related to cancer prevention.

Your participation in the survey is voluntary. Your completion of the survey indicates your consent to participate in the study. You may withdraw from the study by deleting responses before submission. Your name or your CMHC’s name will not be included in any papers or reports related to this study. Your name, email address and IP address will be used to track survey completion. However, we will not disclose any information that could identify you, such as your name, telephone number, or email. The research team has procedures in place to protect your confidentiality and minimize risk. All de-identified data from the survey will be provided to the CDC at the end of the study.

The survey should take about 20 minutes to complete.

If you have any questions about the study, please contact Project Director, Sue Pfefferle at [email protected], or at (617) 520-2699 or Brooke Steele at [email protected], or at (770) 488-4261.

Survey Consent Information Sheet

Psychiatric Clinicians

Your community mental health center (CMHC) has been randomly selected for participation in a study funded by the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) and conducted by Abt Associates. Through this study, we aim to better understand the capabilities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services.

As a part of this study, we are conducting a survey of CMHC psychiatric clinicians, primarily psychiatrists and psychiatric nurse practitioners. Your participation in this survey will help the CDC better understand the capacity of CMHCs to provide cancer prevention services and the needs of CMHCs for training and resources related to cancer prevention.

Your participation in the survey is voluntary. Your completion of the survey indicates your consent to participate in the study. You may withdraw from the study by deleting responses before submission. Your name or your CMHC’s name will not be included in any papers or reports related to this study. Your name, email address and IP address will be used to track survey completion. However, we will not disclose any information that could identify you, such as your name, telephone number, or email. The research team has procedures in place to protect your confidentiality and minimize risk. All de-identified data from the survey will be provided to the CDC at the end of the study.

The survey should take about 15 minutes to complete.

If you have any questions about the study, please contact Project Director, Sue Pfefferle at [email protected], or at (617) 281-2594, or Brooke Steele at [email protected], or at6 (770) 488-4261.

Interview Consent Information Sheet

Administrators

As part of the Division of Cancer Prevention and Control (DCPC), Centers for Disease Control and Prevention (CDC) Assessment of Cancer Prevention Services at Community Mental Health Centers, Abt Associates is conducting interviews with a sample of community mental health center (CMHC) administrators.

The purposes of the study are to better understand capacities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services. Your perspective will inform the CDC’s understanding of the factors that impact cancer prevention services disparities, with the ultimate goal of improving services.

We anticipate interviewing 25 CMHC administrators in total. Please note:

• Your participation is voluntary, and you may choose not to participate in the study.

• The interview will last approximately one hour.

• We would like to audio record the discussion to ensure that we capture everything that is said. The recording will only be used to check our notes and will be destroyed once we have completed our analyses. The recordings will not be shared with anyone outside Abt Associates.

• The discussion will be confidential. Your answers will be combined with those of respondents from other CMHCs. Your responses will not be linked with your name or the name of your practice. The research team has procedures in place to protect your confidentiality and minimize risk.

• Your name and the name of your practice will not be shared, without your permission, with any other entity outside of the research team at Abt Associates or appear in any reports. At the end of the study all data from all interviews will be provided to the CDC, omitting identifying information.

• You can also refuse to answer any particular question during the discussion without affecting your continued participation in the interview.

Do you have any questions about this before we get started?

Do I have your permission to record the interview? If you do not want us to record the interview we will simply take notes.

If you have any questions about the study, please contact Project Director, Sue Pfefferle at [email protected], or at (617) 520-2699 or Brooke Steele at [email protected], or at (770) 488-4261.

Interview Consent Information Sheet

Psychiatric Clinicians

As part of the Division of Cancer Prevention and Control (DCPC), Centers for Disease Control and Prevention (CDC) Assessment of Cancer Prevention Services at Community Mental Health Centers, Abt Associates is conducting interviews with a sample of psychiatric providers, primarily psychiatrists and psychiatric nurse practitioners, at community mental health centers (CMHCs).

The purposes of the study are to better understand capacities of CMHCs to provide cancer prevention and screening services to persons with mental illness, to identify barriers to providing such services, and to propose strategies to addressing these barriers and facilitating such services. Your perspective will inform the CDC’s understanding of the factors that impact cancer prevention services disparities, with the ultimate goal of improving services.

We anticipate interviewing 25 CMHC psychiatric clinicians in total. Please note:

• Your participation is voluntary, and you may choose not to participate in the study.

• The interview will last approximately one hour.

• We would like to audio record the discussion to ensure that we capture everything that is said. The recording will only be used to check our notes and will be destroyed once we have completed our analyses. The recordings will not be shared with anyone outside Abt Associates.

• The discussion will be confidential. Your answers will be combined with those of respondents from other CMHCs. Your responses will not be linked with your name or the name of your practice. The research team has procedures in place to protect your confidentiality and minimize risk.

• Your name and the name of your practice will not be shared, without your permission, with any other entity outside of the research team at Abt Associates or appear in any reports. At the end of the study all data from all interviews will be provided to the CDC, omitting identifying information.

• You can also refuse to answer any particular question during the discussion without affecting your continued participation in the interview.

Do you have any questions about this before we get started?

Do I have your permission to record the interview? If you do not want us to record the interview we will simply take notes.

If you have any questions about the study, please contact Project Director, Sue Pfefferle at [email protected], or at (617) 520-2699 or Brooke Steele at [email protected], or at (770) 488-4261.