0920-1154 (24IP) ACEs Partner Interview Consent Form

Attachment 6: ACEs Partner Interview Consent Form

OMB Control No. 0920-1154

Exp. Date 3/31/2026

The public reporting burden of this collection of information is estimated to average 2 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. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).

PARTNER INTERVIEW CONSENT FORM

STUDY TITLE: Formative Research for Adverse Childhood Experiences (ACEs) Messaging

SPONSOR: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

WHAT ARE YOU BEING ASKED TO DO?

We are asking you to participate in an interview. This is part of a research study that will inform the creation of communication messages and materials by the Centers for Disease Control and Prevention (CDC). The purpose of this group is to get your thoughts and opinions on communication messages and concepts related to adverse childhood experiences, and how to prevent them.

WHAT WILL YOU BE DOING?

We will meet virtually in a private Zoom meeting to talk about adverse childhood experiences, or ACEs. We will ask you what you think about several different messages related to ACEs. We will use this information to create adverse childhood experiences prevention materials and messages for organizations that are working to prevent adverse childhood experiences, as well as for the general public.

We will record what people say so that we do not miss what is being said. We will also take notes. We will destroy the recordings and notes as soon as we finish working on our materials and messages. Our job is to:

• Ask you questions,

• Keep the group focused on the topic we want to discuss, and

• Make sure we don’t run out of time.

We want you to feel free to talk openly. We will listen to your ideas and take notes. This interview will take about an hour to complete.

DO YOU HAVE TO DO THIS?

You do not have to be part of this interview. It is your choice. Your participation in this interview is voluntary. You can say that you don’t want to be in the interview and that is fine. You are also free to stop participating at any time. It is important that you feel okay answering the questions honestly. You do not have to answer any questions you do not want to answer.

HOW WILL YOUR PRIVACY BE PROTECTED?

To protect your privacy, we will not ask you to share your full name and we will not write down your name in any of the notes we take.

We will destroy our notes and recording when we finish working on our messages.

WHAT ARE THE RISKS?

There may be some risks from participating in this study. While we are not asking about personal experiences, you may feel distressed or experience psychological or emotional trauma as a result of having to respond to questions about adverse childhood experiences. We will minimize those risks by allowing you to withdraw from the interview at any time. Additionally, you do not have to answer any questions you do not want to. Lastly, we are sharing several counseling and support resources with all focus group participants (at the end of this document) and will share these resources at the beginning of the discussion.

ARE THERE ANY BENEFITS TO BEING IN THIS GROUP?

There are no direct benefits to being in this study. However, you may benefit from knowing your contributions in this discussion could help improve public messaging about ACEs and help prevent ACEs.

WILL YOU RECEIVE PAYMENT?

We will give you a $75 gift card as a token of appreciation after we finish the discussion to thank you for your time, effort and contributions.

WHAT WILL BE DONE WITH THE RESULTS OF THIS INTERVIEW?

We will review information from the interview to inform the creation of future products or materials to help prevent ACEs, such as webpages, videos, and other tools.

OTHER INFORMATION

Please keep a copy of this information sheet for your records. If you have any questions or concerns about this study, you may contact [PI NAME] at [PHONE NUMBER] or via email at [EMAIL ADDRESS]. The study team is also willing to answer any questions or concerns you might have right now or after the discussion.

Please answer yes or no to the following statements:

___ I understand the information that has been provided to me and voluntarily agree to take part in this focus group discussion.

___ I know that I have a choice to be in this focus group discussion or not and can stop participating at any time during the discussion.

__________________________________________________________________________

COUNSELING AND SUPPORT RESOURCES

• Childhelp National Child Abuse Hotline: 1-800-4-A-Child / 1-800-422-4553

  • Website: https://www.childhelphotline.org/

  • Description: The Childhelp National Child Abuse Hotline is a safe, nonjudgmental and inclusive space for those concerned about or affected by child abuse. Its counselors are available to support those concerned about or affected by child abuse and provide appropriate, individualized guidance for those that reach out. Its staff can also help research additional resources that may be available. The Childhelp National Child Abuse Hotline is NOT a reporting line for child abuse. The hotline is NOT connected to emergency services nor is it a replacement for 911 emergency responsive services.

• 988 Suicide & Crisis Lifeline: 988

  • Website: https://988lifeline.org/talk-to-someone-now/

  • Description: The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week, across the United States. The Lifeline is comprised of a national network of over 200 local crisis centers, combining custom local care and resources with national standards and best practices.

• SAMHSA’s National Helpline: 1-800-662-HELP / 1-800-662-4357

  • Website: https://www.samhsa.gov/find-help/national-helpline

  • Description: The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline, also known as the Treatment Referral Routing Service, is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations.

  • Additional Info: Also visit the online treatment locator, or send your zip code via text message: 435748 (HELP4U) to find help near you. Read more about the HELP4U text messaging service.