Revised Facility Consent Form

Facility ID: ___ ___ ___ ___

Sequence #: ___ ___ ___ ___

FORM APPROVED

OMB No.: 1121-0376

EXPIRATION DATE: 1/31/2026

National Inmate Survey

Full Study

Bureau of

Justice Statistics

Consent to Participate in Research - ACASI

COVID-19 Introduction

Before I describe the study, I will tell you about the safety measures I’m taking in response to the COVID-19 pandemic. I use hand sanitizer frequently and clean all surfaces between interviews. I don’t have any symptoms and, to the best of my knowledge, do not have COVID-19, but I can’t guarantee that. I’m following this facility’s masking requirements, but I will wear a mask if you prefer that. Would you like me to wear a mask?

Study Introduction

The National Inmate Survey is a research study being done by the Bureau of Justice Statistics and Westat. You are one of the inmates at this facility who have been randomly selected to participate. Approximately 40,000 inmates will be interviewed at about 300 facilities across the United States. The main purpose of this study is to learn more about sexual assault in jails. Your participation is completely voluntary.

Description of the Study

This interview will take about 35 minutes. To start, I’ll ask you some questions about your background and enter your answers into the tablet device. Next, I’ll show you how to use the tablet and you will complete the rest of the survey on your own. You will be able to see the questions on the screen and listen to them through headphones. You will enter your answers directly into the tablet by touching the screen. I’ll be nearby in case you have questions but won’t be able to see your answers.

You will be randomly assigned to receive either detailed questions about your own experiences with sex and sexual assault while in this facility (such as the types of sexual acts and where they occurred) or questions about your childhood and your experiences before coming to this facility. In addition, you will be asked about your criminal history and military service. You will never be asked to identify anyone by name. You are the only one who will know which questions you are asked. Even I won’t know unless you discuss the questions with me.

<IF AUTHORIZED BY FACILITY: To thank you for participating in the study, we will provide you with a [snack/metered envelope].>

Possible Risks or Discomforts

Some of the questions in this interview are personal and they could make you feel uncomfortable or upset. You can skip any questions you do not want to answer, and you can stop the interview at any time. Please tell me if you want to stop or take a break during the interview. If you find the questions upsetting for any reason, I can also provide you with instructions for contacting a mental health counselor.

Benefits

You will not receive any direct benefits for participating in this study. However, the results of this study may help improve the well-being of inmates in jail facilities across the United States.

Voluntary Participation

If you choose not to participate, or if you begin the survey and decide to stop before the end, the terms or length of your confinement will not be affected, and you will not lose any benefits or services that you now receive or might receive in the future. Whether you participate will not affect your legal status, your relationship with this facility, or any decisions regarding your release from this facility in any way.

Confidentiality

The Bureau of Justice Statistics and Westat are required by federal law to protect your privacy and confidentiality. Your name will never be connected with the information you provide through the tablet. Your answers will be combined with the responses from other inmates and will be used for statistical and research purposes. The information you enter into the tablet will not be shared with anyone at the facility or anyone else who is not working on the study in a way that would identify you or connect your answers to you individually. Secure systems are used to keep your data safe when it is electronically transferred from the tablet to Westat. A dataset of all the answers provided by inmates will be created and used for research in the field of criminal justice. The dataset will not include your name or other personal identifiers. It is a federal crime for anyone on the project team to release your confidential information.

There are, however, some exceptions to our promise of confidentiality. If you tell me that you intend to seriously harm yourself or a specific person or that you plan to commit a crime in the future, I will need to inform correctional staff here or authorities outside the facility who are responsible for protecting inmates.

[FOR 16/17 YEAR OLD RESPONDENTS ONLY]: Also, if you tell me out loud that you have been or are being abused, my supervisor or I will report that information to the agency in this state that investigates abuse. Once a report is made, no member of the project team has control over how the information is used.

Further Questions

You may keep a copy of this form. If you have any questions about the project, you may ask me. If you think of questions about the project later, you may write to the National Inmate Survey at Westat, 1600 Research Blvd., RB 2126, Rockville, MD 20850. If you have questions about your rights as a research participant, you can write to Westat's Institutional Review Board, Human Subjects Protection at the same address.