Form Client Contact For Client Contact For Client Contact Form Supplement for Parents

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 6 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 15E45,Rockville, Maryland, 20857. 

988 Suicide & Crisis Lifeline and Crisis Services Program Evaluation

Client Contact Disposition Form

Parent or Caregiver Supplement

Hello! Your child has been invited to participate in a set of surveys about their experiences with the 988 Suicide & Crisis Lifeline or other crisis services. Please read the information below to learn more about this opportunity and decide if your child has your permission to participate.

Description of Participation: The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services is conducting an evaluation to learn more learn more about the experience of individuals who have received services through the 988 Suicide & Crisis Lifeline or another crisis service provider. SAMHSA is conducting this evaluation with help from Team Aptive, which includes two research and evaluation companies, Aptive Resources and ICF, who are contracted by SAMHSA for the evaluation. Your child is being asked to complete four brief surveys – one now, and others in about 3 months, 6 months, and 12 months – to share their experiences with a healthcare or crisis service that they have recently received. Each survey will take approximately 45 minutes to complete. These surveys ask questions about your child’s experience with crisis and other behavioral health services, along with their suicide or other crisis risk, mental health, and substance use. Your child may also be invited to participate in a one-hour follow-up interview about their experiences. You will receive additional information if your child is selected for an interview.

Rights Regarding Participation: Your child’s participation in this survey is completely voluntary.  

• There are no penalties or consequences to you or your child if they do not participate.  

• Your child may stop the survey or skip a question at any time for any reason.  

• You or your child may contact the evaluation’s Principal Investigator with any questions they or you have before, during, or after completion.  

Privacy: We take every precaution to protect your child’s privacy. Your child’s name and other contact information will only be used to reach them for completing follow-up surveys. It will be stored separately from their survey responses to help make sure that their responses remain confidential and private. Your child’s survey answers will not be provided to you to protect their privacy. However, if survey responses indicate that your child could be at increased risk for suicide, they will be prompted to discontinue the survey and connect with a 988 Suicide & Crisis Lifeline counselor for additional support.

Benefits: Your child’s participation in this survey will not result in any direct benefits to you or to them. However, your child’s input, along with input from others, will help SAMHSA and your crisis services provider agency improve the way that they help people.  

Incentive: In appreciation of your child’s time, they will receive a $20 electronic gift card after completing each survey, or up to $80 total if they complete all four surveys. Those who are selected to participate in an interview will receive an additional $50 gift card after the interview.   

Risks: Some of the questions in this survey ask about services received during crisis situations. As a reminder, your child may skip questions your child does not wish to answer. If at any time your child begins to feel upset while taking this survey, please ask them to stop the survey and call or text 988 to speak to a counselor 24 hours a day/7 days a week. You can also visit the 988 Lifeline Chat to connect with a counselor. Reminders about how to reach someone who can help are included throughout the survey in case your child needs them. 

Contact Information: If you have any concerns about completing this survey or have any questions about the study, please contact Christine Walrath, Principal Investigator, at (646) 695-8154 or christine.walrath@icf.com. 

For any questions related to your rights as they related to this research, please contact the ICF IRB at IRB@icf.com. 

Do you consent (agree) that your child may participate in this study? Yes No

________________________________ ________________________________

Name of Parent/Caregiver (Print) Electronic Signature of Parent/Caregiver

________________________________ ________________________________

Child’s Name (Printed) Today’s Date [Month/Day/Year]

Thank you for providing your permission for your child to participate in this study. Their feedback is important, and we look forward to hearing more from them. If your child expressed interest, they will receive an email with a link to complete the survey soon. Please tell us more about the best way to reach your child by answering the questions below.
What name does your child prefer to be called? [Open ended response]
What is your child’s preferred email address? £My child does not have a preferred email address. [PROGRAMMER: If this field is blank OR ‘My child does not have a preferred email address’ is selected, skip to end of form]		What is a secondary email address that we could use if we can’t reach your child at the first email? £ My child does not have a secondary email address.
We will reach out to your child via email first. Does your child have a phone number where we could contact them if we can’t reach them through email? [Open ended response] £My child does not have a phone number where the study team may reach them. [PROGRAMMER: If this field is blank OR ‘My child does not have a phone number’ is selected, skip to Q10]
May we use this number to reach your child by phone call, text message, or both? Please select all that apply. £Phone Call £Text Message		May we leave a voicemail message for your child at this number? Our message will include only general references to ‘a study about healthcare services that you recently expressed interest in’ and will not include details about your services. £Yes, you may leave a voicemail £No, you may not leave a voicemail
Does your child have a second phone number where we could contact your child if needed? £ My child does not have a second phone number. [PROGRAMMER: If this field is blank OR ‘My child does not have a second phone number’ is selected, skip to Q10]
May we use this number to reach your child by phone call, text message, or both? Please select all that apply. £Phone Call £Text Message	May we leave a voicemail message for your child at this number? Our message will include only general references to ‘a study about healthcare services that you recently expressed interest in’ and will not include details about your services. £Yes, you may leave a voicemail £No, you may not leave a voicemail
What is the best day for us to reach your child? Select all that apply £ Monday £Tuesday £Wednesday £Thursday £Friday £Saturday £Sunday £ My child doesn’t have a preferred day of the week.
What is the best time for us to reach your child on these days? Answer based on your own time zone. Select all that apply £Mornings (8 am – 12 pm) £Afternoons (12 pm – 5 pm) £Evenings (5 pm – 8pm) £It depends on the day. Please specify the best times to reach you here based on the day if applicable: [Open ended response]
What time zone is your child in? This should be the same time zone that you had in mind when you answered the previous question. £Eastern Time £Central Time £Mountain Time £Pacific Time £Other, please specify: [Open ended response]