Model Client Survey Script
Following Introduction to GPRA
I also have a short survey that asks about your experience and satisfaction with the [Grantee’s ATR Program]. I will tell you more about this survey later.
GPRA to Survey Transition
Now I have a short survey that asks you about your experience and satisfaction with the [Grantee’s ATR Program]. Can I tell you more about this?
The questions in this survey are asked as part of a national study of the ATR Program. The survey is meant to help us learn how the program is doing. It will also help find ways to make the program better.
Introduction and Verbal Informed Consent
A government agency called the Substance Abuse and Mental Health Services Administration (SAMHSA) has hired RTI International (RTI) to study the Access to Recovery Program. RTI is an independent research company in North Carolina. The [Grantee’s ATR Program] is helping RTI to distribute this survey. The survey has 11 questions that take about 6 minutes to answer.
There are a few things you should know about the survey:
The survey is voluntary. This means you can skip any questions that you do not want to answer. It also means you can chose not to take part in the survey.
Your answers are private:
I will not see your answers. Your answers will not be reported to the [Grantee’s ATR Program] staff.
Your answers will not be reported in any way that identifies you.
Your answers will be combined with answers from other ATR clients like yourself across the country.
Your answers may be combined with other data collected by the [Grantee’s ATR Program], however no data will identify you. Nothing will be reported on a personal level.
Answering this survey will not affect the services you received or may receive from the [Grantee’s ATR Program]. The [Grantee’s ATR Program] and SAMHSA are committed to providing the best services. They value your thoughts on the ATR Program.
Answering this survey will not affect any parole status, probation status or any other legal status you may have.
This document is for you to keep. (Hand client written informed consent.) It has the information we just discussed. It provides toll-free numbers to contact RTI if you have questions or concerns after answering the survey. Here is a frequently asked questions form (hand client FAQ document) that may answer any questions you may have right now.
Do you have any questions for me?
Do you wish to complete the survey? (If yes, thank client for participation and hand client the survey. If no, thank client for their time and end session per normally used GPRA follow-up procedures)
After you finish the survey, please seal it in this envelope (hand client return envelope). I will mail it to the RTI team that is collecting these surveys.
Allow the client to independently and privately complete the survey.
Model Client Mail Survey Script
(For Telephone GPRA Follow-up)
Following Introduction to GPRA
I also have a short survey that asks about your experience and satisfaction with the [Grantee’s ATR Program]. I will tell you more about this survey later.
GPRA to Survey Transition
Now I have a short survey that asks you about your experience and satisfaction with the [Grantee’s ATR Program]. Can I tell you more about this survey?
The questions in this survey are asked as part of a national study of the ATR Program. The survey is meant to help us learn how the program is doing. It will also help find ways to make the program better.
Introduction and Verbal Informed Consent
A government agency called the Substance Abuse and Mental Health Services Administration (SAMHSA) has hired RTI International (RTI) to study the Access to Recovery Program. RTI is an independent research company in North Carolina. The [Grantee’s ATR Program] is helping RTI to distribute this survey. The survey has 11 questions that take about 6 minutes to answer.
There are a few things you should know about the survey:
The survey is voluntary. This means you can skip any questions that you do not want to answer. It also means you can chose not to take part in the survey.
Your answers are private:
I will not see your answers. Your answers will not be reported to the [Grantee’s ATR Program] staff.
Your answers will not be reported in any way that identifies you.
Your answers will be combined with answers from other ATR clients like yourself across the country.
Your answers may be combined with other data collected by the [Grantee’s ATR Program], however no data will identify you. Nothing will be reported on a personal level.
Answering this survey will not affect the services you received or may receive from the [Grantee’s ATR Program]. The [Grantee’s ATR Program] and SAMHSA are committed to providing the best services. They value your thoughts on the ATR Program.
Answering this survey will not affect any parole status, probation status or any other legal status you may have.
Do you have any questions for me?
(Answer questions.)
Do you wish to complete this survey?
If no, thank client for their time and end session per normally used GPRA follow-up procedures.
If yes (request/confirm mailing address):
Thank you for agreeing to take part in this survey. You will receive a [describe any identifying features such as color or return address so that participant can look for the envelope and not toss it out with the junk mail] in just a few days. The package has the survey and a written copy of the information we just talked about. It provides 2 toll-free numbers to call RTI if you have questions or concerns about the survey. The package also has a frequently asked questions form that may answer any questions you have.
After you complete the survey, please mail it to me using the envelope sent with the survey. Mailing the survey is free. I will mail your survey to the RTI team that is collecting these surveys.
(Mail client the survey package.)
Consent to Participate in an Evaluation Study
Access to Recovery (ATR) Program Cross-Site Evaluation
Client Survey Consent
Introduction
You are being asked to take part in a national study of the Access to Recovery Program. The study is going to measure how the program is doing. This form describes who can be in the study and the risks and benefits of being in the study. This form also tells how we will protect your information and who you can call if you have any questions.
Purpose
RTI International (RTI) is an independent research company in Research Triangle Park, North Carolina. RTI is studying the Access to Recovery (ATR) Program. The questions in this survey are asked as part of a national study of the ATR Program. The survey is meant to help us learn how the program is doing. It will also help find ways to make the program better. This survey is sponsored by a government agency called the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT). RTI is working with the [Grantee’s ATR Program] to distribute this survey. Because you are a client of the ATR Program, we are asking for your help in this important survey.
Procedures
The survey asks questions about your choice of providers and your satisfaction with the ATR Program. If you choose to take part in this survey, you will be asked to complete it only once.
Study Duration
Completing the survey takes about 9 minutes. That includes time for reading the instructions and answering the survey questions.
Benefits
The information collected in this survey will help us learn how the ATR Program is doing. It will also help improve the program. The survey allows ATR clients like you the chance to give their thoughts on the ATR Program.
Privacy
RTI will not be given your name or any other personal identifying information. RTI will not be able to connect your survey answers to you. Your survey answers will be combined with other answers from people across the country. No one’s answers will be reported alone.
Your Rights
This survey is voluntary. That means you can refuse to answer any question. It also means you can choose not to take part in the survey. Answering this survey will not affect any parole status, probation status or any other legal status you may have.
Your Questions
If you have questions about this study, please call (project team member’s name and toll-free telephone number). If you have questions about your rights in this study, please call (IRB contact person and toll-free telephone number).
Please keep this information. By completing the client survey, you are telling us that you understand the information here and agree to take part in this study.
Access to Recovery (ATR) Program Cross-Site Evaluation
Client Survey
Frequently Asked Questions
Who is conducting this study? RTI International (RTI) is conducting this study of the ATR Program. RTI is a private research company. A government agency, the Substance Abuse and Mental Health Administration (SAMHSA) is funding this study. The [Grantee’s ATR Program] is helping to distribute and mail surveys to RTI.
What is the purpose of this study? This study is to help SAMHSA learn about the ATR Program. SAMHSA wants to better understand how the ATR Program works and how it may be improved.
What is the purpose of this survey? This survey is to help us learn about the provider choices you had as a client and about your experience with the [Grantee’s ATR Program]. This survey allows SAMHSA and RTI to get your thoughts on the ATR Program.
How were you selected? Any one receiving ATR-funded services through the [Grantee’s ATR Program] during the survey period may choose to take part in the survey.
What is your role? You are being asked to answer a short survey. If you choose to take part, you will answer the survey on your own and return it in an envelope that looks different if it has been opened after you seal it. This envelope allows RTI to better protect your privacy.
Must you participate? No, this survey is voluntary. We hope that you will choose to answer the survey. If you do not want to answer the survey, you will not lose any services or benefits that you may receive. Answering this survey will not affect any parole status, probation status or any other legal status you may have. We want to protect your privacy. For that reason we do not ask you to sign anything, even a consent form. By verbally agreeing to take part in the survey or by returning a completed survey, you are telling us that you agree to take part in this survey.
How long will this take? The survey questions take about 6 minutes to answer. Getting your consent or agreement to complete the survey takes about 3 minutes. That means in all, this survey takes about 9 minutes.
Who will see your answers? Your answers will be seen only by RTI. The [Grantee’s ATR Program] and your service provider will not see your individual answers. At no time will your individual answers be reported.
What if I have questions? If you have questions about this study, please call Cassie Williams at 1-800-###-####, extension 2----. If you have questions about your rights in this study, please call RTI's Office of Research Protection at 1-866-###-#### (a toll-free number).
Cross-Site Access to Recovery Program Evaluation
Client Survey
Mail Survey Instructions
Thank you for agreeing to take part in the ATR client survey. This survey is an important part of learning about your experience with the [Grantee’s ATR Program].
This packet contains three documents: (1) the survey questionnaire, (2) an informed consent, and (3) a frequently asked questions form. The informed consent has the information we talked about on the phone. It also lists 2 toll-free phone numbers you can call if you have questions. The frequently asked questions form may answer questions you have about the survey.
Please follow the instructions on the survey questionnaire and mail your completed survey in the postage-paid envelope. The [Grantee’s ATR Program] will not open the envelope or see your answers. They will mail the survey to RTI. Only RTI will see your completed survey.
Tear-away Face Page
Access to Recovery Cross-Site Evaluation
Client Survey Supplement Form
Private
Local GPRA Administrator:
If a client agrees to participate in the ATR Client Survey, please follow the directions below.
[Grantee-specific handling instructions will be inserted here]
Alternative Client ID or Dummy ID: XXXXXXXX
[Printed or recorded here and on survey form]
(GPRA ID or local grantee ID) _______________________
Please remove this page from the survey instrument prior to handing survey to client.
[Grantee-specific return instructions will be inserted here]
Please do not store or mail this form with a completed survey.
| File Type | application/msword |
| File Title | ATTACHMENT 6: |
| Author | sorme |
| Last Modified By | sorme |
| File Modified | 2009-03-16 |
| File Created | 2008-10-14 |