Consent Form

Attachment C

Release and Consent Form

OMB No. 0930-0196

Expiration Date: 9/30/19

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 0930-0196.  Public reporting burden for this collection of information is estimated to average 90 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, 5600 Fishers Lane, Room 15E57-B, Rockville, MD 20857.

RELEASE AND CONSENT FORM

Purpose: The Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is conducting an assessment about two concepts developed in English to produce a Public Service Announcement (also called PSA) targeting military families about underage drinking and substance use prevention. This assessment is being conducted on SAMHSA’s behalf by Synergy Enterprises, Inc. The purpose of this assessment is to explore the relevance, understanding and appealing of these two PSA concepts materials among military parents/caregivers of children 9 to 15 years old.

Procedures: If you participate in this assessment you will be in a group of approximately 10 other parents/caregivers of children ages 9–15. There will be a facilitator who will ask questions and facilitate the discussion, and a note taker to write down the ideas expressed within the group. We will also be recording the session to help clarify the information written down by the note takers, should there be any questions in summarizing the results. If you volunteer to participate in this assessment, you will be asked some questions regarding your opinions, comments and suggestions about the visual, audio elements, as well as the messages relevance and call for action. We will not be asking specific information about your alcohol/substance use or your children’s use. No personal information will be included in the notes; we are using first names only during the session.

Your participation is completely voluntary. You may withdraw from the focus groups at any time without penalty. The estimated time for completing this focus group is 90 minutes.

Benefits and Risks: Your participation may benefit you and other parents and caregivers of children by helping SAMHSA to develop information that is relevant to parents aiming to reduce underage drinking and substance use. No risk greater than those experienced in ordinary conversation are anticipated. Everyone will be asked to respect the privacy of the other group members. All participants will be asked not to disclose anything said within the context of the discussion, but it is important to understand that other people in the group with you may not keep all information private.

Privacy: Stakeholder feedback will be analyzed by Synergy Enterprise, Inc. staff and reported to SAMHSA. No individual participant will be identified or linked to the results. Focus group records, including this consent form signed by you, may be inspected by SAMHSA or the Office of Management and Budget which oversees all data collection conducted on behalf of government funded agencies. The results of this assessment will be used to improve the National Media Campaign and as part of the National Evaluation and Reporting. Your identity will not be disclosed. All information obtained in these groups will be protected. All materials will be stored in a secure location by Synergy Enterprises, Inc. and access to files will be restricted to paid professional staff.

Consent:

By signing below, you are indicating that you fully understand the above information and agree to participate in this focus group.

Participant's signature: ______________________________________________________________

Printed name: ___________________________________________ __________________________

Date: _____________________________________________________________________________

If you have any questions or concerns about this assessment, please contact Ms. Elaine Rahbar, Synergy Enterprises, Inc. (240) 485-1700

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