Consent Form_Parent caregiver Interviews Consent Form

Attachment 7: Consent Form for Parent/Caregiver Interviews

Intro OMB Control Number:  ______

Expires: ________

Logo for SAMHSA and CSAP

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 ____, expires: _____.  Public reporting burden for this collection of information is estimated to average 10 minutes per respondent, including the time for reviewing instructions.  Send comments regarding this burden to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 16E89B, Rockville, MD  20857.

Authorization and Release

The undersigned hereby authorizes the U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA) to use the information, feedback, and opinions I provided through a telephone interview to assess the usefulness of the “Talk. They Hear You.” campaign in facilitating conversations with your children about underage drinking.

Procedures: If you participate in this study, you will be contacted by telephone to answer follow-up questions regarding your participation in the underage drinking survey. We will also be recording the telephone call to help clarify the information written down by the facilitator, should there be any questions in summarizing the results. If you volunteer to participate in this telephone interview, you will be asked some questions about your experience discussing underage drinking, including whether conversations were facilitated by exposure to the “Talk. They Hear You.” campaign materials. No personal information will be included in the notes; we are using first names only during the telephone call.

Your participation is completely voluntary. You may withdraw from this study at any time without penalty.

Benefits and Risks: Your participation may benefit you and other caregivers concerned about the impact early of alcohol use and efforts to prevent occurrences of underage drinking. No risk greater than those experienced in ordinary conversation are anticipated. First names will only be used by the facilitator for the purpose on contacting individuals, and will no longer be associated with the information provided following the interview.

Consent:

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

Participant's signature: _______________________________________________________

Printed name: ______________________________________________________________

Date: ______________________________________________________________________

If you have any questions or concerns about this study, please contact Elaine Rahbar at 240-485-3606