MICS-Follow-up Interview Informed Consent

Clinical Interview Informed Consent
(Note – This script is also included in the Blaise Instrument Specs, Attachment MICS-3)
First, I need to share some key information about the study. You have been selected for a follow-up
study to the National Survey on Drug Use and Health. This study, sponsored by the U.S. Department of
Health and Human Services, will ask questions about mental health and consists of one interview.
The interview should take about 60 minutes to complete. Your participation is voluntary, and you can
refuse to answer any questions. If you decide to participate, I will ask you questions using a laptop
computer. I will ask for permission to record the interview to ensure I did it properly. You can still be
interviewed even if you do not allow the interview to be recorded. If you agree to be recorded, please
know that your recording and interview responses may be de-identified and used for quality or training
purposes for this research project, but will not be used for other research studies in the future. You have
received $30 for agreeing to participate in this interview.
All information collected for this study will be kept confidential and used only for statistical purposes.
You cannot be identified through any information you give us. Your name and address will never be
connected to your answers. However, there are some exceptions to this privacy rule. If you tell me
about the abuse of a child or that you plan to hurt yourself or others, we may need to notify a mental
health professional or other authorities.
If you would like to know the full risks and benefits of the study, and how the information will be used, I
can read the more detailed informed consent to you now, or you can read it at
https://nsduhweb.rti.org/respweb/final_extended_informed_consent.pdf.
Do you agree to participate in this study?