Attachment 8 - Other

Attachment 8: Document 1 – Partner/Collaborator Consent Form

Form Approved
OMB No. ####-####
Expiration Date: ##/##/####

Consent Form for Participation in the Targeted Capacity Expansion Program for Substance Abuse
Treatment and HIV/AIDS Services Multi-site Evaluation

PARTNER COLLABORATOR SEMI-STRUCTURED INTERVIEWS

A.
BACKGROUND AND PURPOSE
JBS International, the Alliance for Quality Education, Battelle Memorial Institute, and the Oregon Health & Science
University (JBS team) have a contract with the Substance Abuse Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment (CSAT) to conduct a Multi-Site Evaluation of the TCE-HIV
program. The JBS team is not part of CSAT or any other federal agency.
The purpose of this study is to learn more about the effect of outreach/pretreatment and substance abuse treatment
programs supported by TCE-HIV funding. The goal of the study is to improve outreach/pretreatment and substance
abuse treatment for racial and ethnic minorities at risk for HIV/AIDS. Information from your participation will help
the JBS team understand how programs can better reduce substance abuse and HIV risk behaviors.
You are being asked to participate in this study because you represent a community partner who collaborates with a
TCE-HIV program.
B.
PROCEDURES
If you agree to participate, the following will occur:
• You will complete a form providing background information (e.g., age, gender, and length of partnership
with TCE-HIV program).
• You will take part in an interview. The interview will be about your role, activities, and your collaboration
with the program.
• The interview will last approximately 30–40 minutes.
• The interview will take place at a time and place convenient to you.
• The interview discussion will be audio taped to ensure accuracy in reporting your statements.
• Neither your name nor identity of your program will be used in any published reports.
All information you provide is anonymous. Input you provide during the interview will be combined with
information from other interviews from across the United States. The combined information will be analyzed. Only
combined results will be presented in reports.
C.
RISKS
The risks for participating in the study are expected to be minimal.. Responding to the questions does not involve
great risk, but this activity might be tiring. The JBS team does not have a program to pay you or provide medical
care if you are hurt by participating in this research project.
Notice to Respondents
Public reporting time for this collection is estimated to average 30–40 minutes, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA OMB
Officer, 1 Choke Cherry Road Room 7-1044, Rockville, MD 20850. 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. The OMB control number for this project is
XXXX-XXXXX.

1

Attachment 8: Document 1 – Partner/Collaborator Consent Form
D.
PRIVACY
The privacy of the information we collect about you will be very carefully protected. The evaluation staff is trained
on handling sensitive data and the importance of privacy. All of the data will be kept in locked files at JBS
International, and only the official project staff will have access to these files. At the end of the project all data will
be given to CSAT. The data that is given to CSAT will not include names or participant identification.
E.
BENEFITS
There is no direct benefit to you for participating in this research project. However, the information you share might
benefit the TCE-HIV program and similar programs targeting persons who abuse substances and are at risk for HIVAIDS.
F.
RIGHT TO REFUSE OR WITHDRAW
Your participation in this interview is completely voluntary. You may end your participation in the interview at any
time. If you refuse to participate, there will be no penalty or loss of benefits to you.

G.
PERSONS TO CONTACT
If you have any questions about this study, please contact Dr. Resa Matthew at JBS International.
Resa Matthew, Ph.D.
JBS International
5515 Security Lane, Suite 800
Bethesda, MD 20852
(301) 495-1080
rmatthew@jbsinternational.com
If you have any concerns about your rights in this study or any questions about injuries related to the research
project, please contact Dr. Amanda Gmyrek of the JBS International Institutional Review Board.
Amanda Gmyrek, Ph.D.
JBS International
5515 Security Lane, Suite 800
Bethesda, MD 20852
(301) 495-1080
agmyrek@jbsinternational.com

YOUR CONSENT
You have read this consent form. You have been given a chance to ask questions, and you feel that all of your
questions have been answered. You know that you are free to participate in the interview or not. You know that after
choosing to participate in the interview, you may stop at any time without penalty. You are signing below to indicate
that you agree to participate in this interview and give permission for your responses to be audio recorded.

_____________________________________

__________________

Participant Name (Print)

Date

_____________________________________
Participant Signature

2

Attachment 8: Document 1 – Partner/Collaborator Consent Form

I acknowledge that I witnessed the participant sign this consent form.

_____________________________________

__________________

Witness’ Name (Print)

Date

_____________________________________

__________________

Witness’ Signature (Print)

Date

_____________________________________
Researcher’s Signature

__________________
Date

3