Appendix B_Consent Form_Site Visit Interview

INFORMED CONSENT FORM

SITE VISIT DISCUSSION GUIDE

INTRODUCTION

You are being invited to take part in an in-person interview that is being conducted as part of the national Cross-site Evaluation of Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health). Project LAUNCH is a recent initiative through the Substance Abuse and Mental Health Services Administration (SAMHSA) aimed at promoting the wellness of young children ages birth to 8 by addressing the physical, social, emotional, cognitive, and behavioral aspects of their development. This national evaluation is sponsored by SAMHSA and the Administration for Children and Families (ACF).

Abt Associates Inc., a research consulting firm, is carrying out the national Cross-Site Evaluation. As part of the evaluation, annual site visits to Project LAUNCH grantees are being conducted to speak with grant-funded staff and other key partners and stakeholders. The purpose of these interviews is to understand grantees’ progress in program implementation and service delivery and to collect data about Project LAUNCH activities aimed at infrastructure development and systems change at the State, Tribal, and community levels.

The interview will require approximately _________minutes. You are being asked to provide your informed consent to participate in the interview.

PURPOSE

The findings from the discussion will be summarized, along with other data that are collected, to describe Project LAUNCH service delivery processes, infrastructure development, and system change activities. The discussion will be kept private.

RISKS OF TAKING PART IN THE STUDY

This evaluation represents minimal risk to you. The primary risk associated with participation in the evaluation is a breach of privacy; however, numerous procedures are in place to minimize this risk. You can choose not to answer a particular question during the interview or refuse to discuss a particular topic with no penalty to you. Your name will not be used in any summary reports that result from this site visit and no comments will be attributed to you.

COSTS AND FINANCIAL RISKS

There are no costs for participating in the interview.

POSSIBLE BENEFITS OF TAKING PART IN THE STUDY

By participating in this interview, you are supporting the national cross-site evaluation effort and the development of knowledge about what makes programs like Project LAUNCH effective and replicable in other States and communities.

COMPENSATION

You will not receive compensation for participating in the interview.

PRIVACY

Information collected in the survey will be kept private. Protections will be in place to ensure privacy to the maximum extent allowed by law. Notes from this interview will be labeled with a study code and will not include your name. All study files will be de-identified and stored in locked offices at Abt Associates Inc. or on secure, password-protected internet servers at Abt Associates Inc. The comments made during the interview will be used in reports to the government, in summary form only; no names will be included in the report.

PARTICIPATION IS VOLUNTARY

It is up to you to decide whether to participate in the interview. If you decide not to participate in the interview, you will not be penalized in any way now or in the future. In addition, a decision not to participate will not affect your relationship with SAMHSA or ACF now or in the future. Even if you agree to participate, you are not required to answer all the questions.

QUESTIONS

You may call Deborah Walker of Abt Associates Inc. (617-349-2390) to obtain more information. You may also phone Teresa Doksum, Senior Finance and Administration Manager - IRB Administrator (617-520-2896) if you have other questions about your rights as a participant in this evaluation. Please note that calling these numbers will incur a toll.

STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS INTERVIEW

I have read and understand this information. I have had all my questions answered fully and I freely and voluntarily choose to participate in the interview. I have been given a copy of this consent form.

____________________ ____________________ _______________________

Name (Please print) Signature Date