D8. TUP-S-A Consen D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.do

Training ID:  OMB No. 0930-0286

Expiration Date: XXXX-XXXX

Cross-site Evaluation of the Garrett Lee Smith Memorial (GLS)

State Tribal Youth Suicide Prevention and Early Intervention Program

Training Utilization and Preservation–Survey

Adolescent Version

CONSENT-TO-CONTACT and ASSENT FORM

Training Name:

Date of Training/Today’s Date: ______________________________________________

Training Location Zip code: ______________________________________________

As part of the Garrett Lee Smith Youth Suicide Prevention and Early Intervention Cross-site Evaluation, we would like to interview adolescents who participated in the training activity provided by [INSERT NAME OF SCHOOL OR GRANTEE]. We would like to ask if you will allow [YOUTH NAME] to participate in the Training Utilization and Preservation Survey, a brief confidential survey that will be administered via text message to participants of youth suicide prevention training programs. The survey will take approximately 10 minutes and will be conducted via text message. If your child is interested in participating in the interview, he/she will be provided with a $10 Amazon gift card incentive in appreciation of their time.

[YOUTH NAME]’s answers to the survey questions will be kept private except as otherwise required by law. Their name will not be linked with the information on their survey. Their name will not be used in any reports about this evaluation. We will need to collect a phone number and other contact information so that we can contact your child to complete the follow-up survey in 3 months. The survey asks questions about what they learned during this training; how they have used what they learned; how it has impacted the way they interact with their peers who may be at risk for suicide in their community; and about their history of suicide ideation and attempts. Findings from the survey will assist in informing the Substance Abuse and Mental Health Services Administration about suicide prevention activities and training experiences of adolescents. All answers are strictly confidential; the responses will not be linked to you or your child’s name or their telephone number.

Does [YOUTH NAME] have your permission to participate in the Training Utilization and Preservation Survey?

• Yes

• No

If Yes, please provide your child’s contact information below:

YOUTH Name:		Best Contact? (select yes or no)
Home Phone:		Yes No What’s the best time to call this Number?
Cell Phone:		Yes No What’s the best time to call THIS Number?
home Address:
Personal E-mail 1:
Personal E-mail 2:

ASSENT-TO BE-CONTACTED

We are inviting you to participate in the study because we want to understand what you learned during this training, how you are using what you learned, and if it has changed the way you talk to your peers. This survey will take about 10 minutes and will be done through text messages to your cell phone. You can stop answering the questions at any time. As a thank you we will give you a $10 Amazon gift card. Your answers to your questions will be private. We will not share your responses with your name. All of our reports combine many people’s responses so no one can be identified.

Please sign below if it is OK for us to send you a text message and ask you some questions in about 3 months.

Printed Name of Youth Signature of Youth (required if 14 years or older) Date

Printed Name of Parent or Legal Guardian Signature of Parent or Legal Guardian Date

If you have any concerns or questions about your participation in this study, please contact Christine Walrath, Principal Investigator, at (212) 941‑5555 or christine.walrath@icfi.com.

Whether you selected yes or no above, please return this page to the training facilitator.

Thank you!

Training Utilization and Preservation–Survey: Adolescent Consent-to-Contact and Assent Form Page 2