Exec-Admin Consent Form

OMB No. 0930-####

Expiration Date: ##/##/####

Consent Form for Participation in the VITEL Program Evaluation

EXECUTIVE/Administrative Staff Semi-Structured Interviews

1. Background and Purpose

XXXX has a contract with the Substance Abuse Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) to conduct an Evaluation of the VITEL program. The XXXX team is not part of CSAT or any other federal agency.

The purpose of this study is to learn more about the effect of IPV screening and referral to trauma-informed interventions, substance use disorder treatment, and HIV services supported by VITEL funding. The goal of the study is to improve IPV outreach and screening and referral to trauma-informed services for racial and ethnic minority women in substance use disorder treatment who are at risk for or living with HIV/AIDS. Information from your participation will help the XXXX team understand how programs can better reduce IPV, substance use/abuse, and HIV and related risk behaviors.

You are being asked to participate in this study because you are an administrator of a VITEL 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 years at current staff position).

• You will take part in an interview. The interview will be about your role, activities, and experiences as an administrator of this program.

• The interview will last approximately 60 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 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. 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 minor. Responding to the questions does not involve great risk, but this activity might be tiring. The XXXX team does not have a program to pay you or provide medical care if you are hurt by participating in this research program.

Notice to Respondents

Public Burden Statement: 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 0930-xxxx. Public reporting burden for this collection of information is estimated to average 60 minutes per respondent, per year, 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 Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

D. PRIVACY

The information that you provide will be kept private. The interview discussion will not be shared with anyone but the researchers conducting this study, except as otherwise required by law. All of the data will be kept in locked files at XXXX. The consent form that you sign will be kept in a locked file separate from your completed participant information form. Only the official program staff will have access to these files. At the end of the program 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 program. However, the information you share might benefit the VITEL program and similar programs targeting persons who are at risk for IPV, substance use/abuse, and HIV.

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 XXXX XXXXX at XXXX.

Name

XXX Main Street

XXXXX, NY10036

(XXX) XXX-XXXX

XXX@XXXX.com

If you have any concerns about your rights in this study or any questions about injuries related to the research program, please contact XXX XXXXXX of the XXXX Institutional Review Board.

Name

XXX Main Street

XXXXX, NY10036

(XXX) XXX-XXXX

XXX@XXXX.com

H. 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’s Name (Print) Date

_____________________________________

Participant’s Signature

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

_____________________________________ __________________

Witness’ Name (Print) Date