2021 OMB Package_UAD TTHY_Focus Groups Consent Form_Attachment C

Attachment C

Focus Group Release and Consent Form

OMB No. 0990-0459

Expiration Date: 8/31/2023

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0990-0459. Public reporting burden for this collection of information is estimated to average approximately 100 minutes (about 1 hour and 40 minutes) per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, MD 20857.

RELEASE AND CONSENT FORM

Purpose: The Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is conducting an assessment about a concept developed in English to produce one public service announcement (also called PSA) targeting parents and caregivers about underage drinking and other drug/substance use prevention. This focus group is being conducted on SAMHSA’s behalf by Synergy Enterprises, Inc. in collaboration with EurekaFacts. The purpose of the focus group is to explore the relevance, understanding, relatability, and appeal of this PSA concept among parents/caregivers of children under age 21.

Procedures: If you participate in this assessment, you will be in a group of approximately seven other parents/caregivers of a child(ren) ages 10–20. There will be a facilitator who will ask questions and facilitate the discussion, and a note taker to write down the ideas expressed within the group. We will also be recording the session to help clarify the information written down by the note takers, should there be any questions in summarizing the results. If you volunteer to participate in this focus group, you will be asked some questions regarding your opinions, comments, and suggestions about the visual and audio elements, as well as the messages relevance and call to action. We will not be asking specific information about your alcohol or other drug/substance use or your child’s(ren’s) use. No personal information will be included in the notes; we are using first names only during the session.

Your participation is completely voluntary. You may withdraw from this assessment at any time without penalty. The estimated time for completing this focus group is approximately 100 minutes (about 1 hour and 40 minutes).

Benefits and Risks: Your participation may benefit you and other parents and caregivers by helping SAMHSA develop information that is relevant to parents and caregivers aiming to reduce underage drinking and other drug/substance use. No risk greater than those experienced in ordinary conversation are anticipated. Everyone will be asked to respect the privacy of the other focus group participants. All participants will be asked not to disclose anything said within the context of the discussion, but it is important to understand that other people in the group with you may not keep all information private.

Privacy: Stakeholder feedback will be analyzed by EurekaFacts and Synergy Enterprise, Inc. staff and reported to SAMHSA. No individual participant will be identified or linked to the results. Focus group records, including this consent form signed by you, may be inspected by SAMHSA or the Office of Management and Budget (OMB) which oversees all research conducted on behalf of government funded agencies. The results of this assessment will be used to improve the “Talk. They Hear You.” National Media Campaign and as part of the national evaluation and reporting. Your identity will not be disclosed. All information obtained in this assessment will be protected. All materials will be stored in a secure location by Synergy Enterprises, Inc. and access to files will be restricted to paid professional staff.

Consent:

By signing below, you are indicating that you fully understand the above information and agree to participate in this focus group.

Participant’s signature: ______________________________________________________________________________

Printed name: ______________________________________________________________________________

Date: ______________________________________________________________________________

If you have any questions or concerns about this assessment, please contact Mr. Ryan Parks, Synergy Enterprises, Inc. (571) 215–0857.

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