TUP-S Campus Consent to Contact Form

OMB No. xxxx-xxxx

Expiration Date: Date

Training ID: 

Garrett Lee Smith Memorial (GLS) National Outcomes Evaluation

Campus Suicide Prevention Program

Training Utilization and Preservation Survey (TUP-S)

Consent to Contact Form

Training Name:

Date of Training/Today’s Date:

Training Location Zip code:

As part of the Garrett Lee Smith (GLS) Youth Suicide Prevention and Early Intervention Cross-site Evaluation, we will be interviewing individuals who participated in the training activity you just completed. The Training Utilization and Preservation Survey is a telephone survey that will be administered to participants from a random sample of Campus suicide prevention gatekeeper training programs and collect information about gatekeeper knowledge, attitudes, and behaviors following their trainings. Your participation in this brief survey is completely voluntary. Your answers to the survey questions will be kept private except as otherwise required by law. Your name will not be linked with the information on your survey. Your name will not be used in any reports about this evaluation. We are interested in contacting you again within the next 3 months to ask you some questions about: what you learned during this training; how you have used what you learned; and what impact it has had on your identification and referral of youth at risk for suicide in your community. Findings from the survey will assist in informing the Substance Abuse and Mental Health Services Administration about suicide prevention activities and training experiences.

The survey will take approximately 10 minutes and will be conducted over the telephone by a member of the cross-site evaluation team. If you are selected to participate in the interview, in appreciation of your time, we will provide you with either a $10 Amazon gift code or we will mail you a $10 money order.

Are you interested in being contacted about possible participation in the Training Utilization and Preservation Survey?

• Yes

• No

If you are interested in participating in this important effort, or in learning more about the Training Utilization and Preservation Survey, please provide your contact information below. If you are selected to participate in the interview, a member of the cross-site evaluation team will contact you. Participants for the survey will be randomly selected from a complete list of interested training participants.

Name:		Best Contact? (select yes or no)
Home Phone:		Yes No What’s the best time to call this Number?
CAMPUS Phone:		Yes No What’s the best time to call this Number?
Cell Phone:		Yes No What’s the best time to call THIS Number?
CAMPUS Address:
home Address:
Campus E-mail:
Personal E-mail:

If you have any concerns or questions about your participation in this study, please contact Christine Walrath, Principal Investigator, at (212) 941-5555.

Whether you selected yes or no above, please return this page to the training facilitator.

Thank you!

Campus TUP-S Consent to Contact Page 1

12/2015