Appendix_J_CSE

Appendix I. CSE Interview Consent Form

INTRODUCTION

You are invited to take part in an 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 an 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, a research consulting firm, is carrying out the national Cross-Site Evaluation. As part of the evaluation, telephone interviews with 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. Approximately 10 people from each site will be asked to participate in these interviews. Telephone interviews are conducted in years one, three, and four of each cooperative agreement with site visits in year two.

Interviews will require between 45 to 90 minutes of your time. The length of time your interview takes will depend on your role on the project, as shown in Table 1 below.

Table 1. Length of Interview by Respondent Role

Child Wellness Coordinator	90 minutes
Chair of Local Child Wellness Council	60 minutes
Local Stakeholder	45 minutes
State Child Wellness Coordinator	75 minutes
Chair of State Child Wellness Council	75 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 confidentiality; 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 telephone interview 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 reported in aggregate form only; no names will be included in any materials resulting from this evaluation, such as government reports, publications, journal articles, or other information dissemination vehicles.

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 Meg Gwaltney of Abt Associates Inc. (301-634-1898) to obtain more information. You may also phone Katie Speanburg, IRB Administrator, (617-520-2499) 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