Form Consumer Study Int Consumer Study Int Consumer Study Interest Form

OMB No. 0930-NEW

Expiration Date: XX/XX/XXXX

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 15 minutes per respondent per administration, 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.

Zero Suicide Evaluation

Consumer Study Interest Form (C-SIF)

Description of Participation

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services is evaluating SAMHSA’s Zero Suicide in Health Systems program. Aptive Resources along with its partner ICF (Team Aptive) are contracted by SAMHSA to conduct this evaluation. We are asking you to participate in this survey. This survey will take about 15 minutes to complete.

Right Regarding Participation

Your participation in this survey is completely voluntary.

There are no penalties or consequences to you if you do not participate.  

You may stop the survey or skip a question at any time for any reason.  

You may contact the evaluation principal investigator with any questions you have before, during, or after completion.  

Privacy

We will take every precaution to protect your privacy.

All survey responses will be confidential. Your name will never appear in any report. All findings will be reported in aggregate; that is, they will be combined with responses from other individuals. If you are selected to participate in follow-up surveys your responses across administration will be linked with a unique identifier, but your name and responses will not be linked. Your individual responses will not be shared with anyone, including your provider or other grantee-funded staff.  

Contact information will be entered into a password-protected database which can only be accessed by a limited number of individuals (selected Team Aptive staff) who require access.

Benefits

Your participation will not result in any direct benefits to you. However, your input will contribute to a national effort to prevent suicide.   

Incentive

In appreciation the respondent will receive a $5 electronic gift card for completing this survey.

Risks

Completing this survey poses few, if any, risks to you. Some questions may make you feel uncomfortable. You can choose not to answer any question for any reason. You may choose to stop the survey at any time, or not answer a question for whatever reason. You will not be penalized for stopping. You can contact the principal investigator of the project at any time.   

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 IRF at IRB@icf.com.

Thank you for helping us invite this consumer to participate in the survey opportunity. We will use the information we learn to better understand how we can support behavioral health consumers at risk for suicide, as well as document all of the successes that you have helped this consumer achieve throughout their care.

This form consists of two sections that need to be completed during a consumer’s first appointment after enrolling in a suicide care management plan or other suicide-specific services.

1. Section 1 (Staff-Completed): This section contains a few brief questions about the consumer’s care. Staff members should complete this section.

2. Section 2 (Participant-Completed): These questions should be asked directly to interested participants. Providers can choose to ask verbally during an appointment or provide a tablet, computer, or other device for participants to complete these questions directly. Additional instructions are available in Section 2 to help guide a participant through the questions if they are completing it through self-report.

Section 1. Consumer and Screening Information

1. Does this consumer have a National Outcome Measures (NOMS) Participant ID?

• Yes. Please list the NOMS ID here: _______________________

• No

• I don’t know

2. When was this consumer’s first appointment with your agency? _____________

3. Does this consumer have an active suicide care management plan?

• Yes

• No

• I don’t know

Section 2. Study Interest and Contact Information

Consumer Study Interest Form Administration Guide

This section of the form asks questions about the participants’ interest in study participation and their suicide risk. These questions may be asked verbally to participants during an appointment, or you may hand a tablet, computer, or other device to the participant and ask them to complete the questions independently.

When you are ready to proceed to the participant questions, click next below. If you are asking participants to self-report this information directly, you may pass them the device after clicking next. Participants will be asked to hand the device back to you after the questions are complete. Those who complete this section are eligible for a $5 gift card. Information needed to redeem this gift card will be shown at the end of the survey. Please also be sure to provide consumers with this gift card information if you are asking questions to participants verbally.

You’re invited to take part in a study about your experiences with your healthcare provider. If you’re interested, there are a few things you need to know:

1. Initial Questions: You’ll answer a few questions now. These will help us understand your current mental health and care experiences.

2. Surveys: You’ll also receive a survey via email in a few days, as well as a follow-up survey in about six months. These surveys will ask you additional questions about your mental health, the services you have received, and your experiences with care.

3. Optional Interview: If you would like, you also have the opportunity to participate in a 60-minute interview to share more about your experiences. If you are interested and selected to participate, you will receive an additional email or phone call to schedule your interview. Interviews will take place over the phone or through a video call.

4. Purpose: By participating, you’ll help us learn how the services you received have impacted you over time. We are interested in your experiences because we want to improve support for people like you throughout their care journey.

5. Time Commitment: The two surveys will take approximately 20-25minutes each, or up to 50 minutes total. If you are selected to participate, the interview will take approximately 60 minutes.

6. Survey Gift Cards: As a thank-you, you’ll receive up to $30 total in gift cards, including:

   • $5 Gift Card Today after you complete the initial questions and provide your contact information.

   • $10 Gift Card after you complete the first follow-up survey in a few days.

   • $15 Gift Card after  completing the second survey in about six months.

7. Interview Gift Cards: Those who are selected to participate in the optional interviews will receive an additional $30 gift card after completing the interview. Interviews will be scheduled on a rolling basis, so keep an eye on your email for more information from the study team.

Thank you for considering participation! Your insights matter.

This study is being conducted by the Substance Abuse and Mental Health Services Administration, or SAMHSA, with help from Team Aptive. Team Aptive includes two research and evaluation companies, Aptive Resources and ICF, who are contracted by SAMHSA for the evaluation.

Are you interested in participating in the two surveys? You will receive more information about participation from the study team if you select ‘yes,’ below, but can still choose not to complete the surveys at any time if you change your mind.

• Yes

• No

Are you interested in participating in the optional interview? You will receive more information about participation from the study team if you select ‘yes,’ below, but can still choose not to complete the interview at any time if you change your mind.

• Yes

• No

(PROGRAMMER: SKIP TO END OF FORM IF NO IS SELECTED FOR BOTH QUESTIONS. DISPLAY THE FOLLOWING TEXT: Thank you for taking the time to consider our request. Your decision not to participate will have no impact on you or the services you receive from your healthcare provider. If you were asked to fill out these questions on your own, please hand the device back to your provider at this time.)

Is it okay if someone from Team Aptive (Aptive Resources or ICF), who are conducting this study on behalf of SAMHSA, contacts you when it is time for your follow-up surveys and/or interview? Future information about the study will come from (insert email address). This information will only be used to send you survey or interview invitations, or reminders about these activities, and will not be linked to your responses.

• Yes

• No

(PROGRAMMER: SKIP TO END OF FORM IF SELECTED AND DISPLAY THE FOLLOWING TEXT: Thank you for taking the time to consider our request. Your decision not to participate will have no impact on you or the services you receive from your healthcare provider. If you were asked to fill out these questions on your own, please hand the device back to your provider at this time.)

If you have any concerns about your participation in this study or have any questions about the evaluation, please contact Christine Walrath, Principal Investigator at cwalrath@icf.com or at 646-695-8154.

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

Please type your name and today’s date below to confirm your consent to be contacted for the purpose described above.

Name Date

The next few questions will ask you about how you’ve been feeling recently. It’s okay to skip any questions that you don’t want to answer or to stop or pause at any time.

4. Please select the option below that best reflects how you’ve been feeling within the past month.

   1. Have you wished you were dead or wished you could go to sleep and not wake up?

• Yes

• No

2. Have you actually had any thoughts of killing yourself? (PROGRAMMER: If ‘No’ is selected, skip to Q5)

• Yes

• No

3. Have you thought about how you might do this?

• Yes

• No

4. Have you had any intention of acting on these thoughts of killing yourself, as opposed to having the thoughts but you would definitely not act on them?

• Yes

• No

5. Have you started to work out, or actually worked out, the specific details of how to kill yourself and did you actually intend to carry out the details of your plan?

• Yes

• No

5. Have you ever done anything, started to do anything, or prepared to do anything to end your life? (PROGRAMMER: If ‘No’ is selected, skip to Q6)

• Yes

• No

1. Did this occur within the past three months?

• Yes

• No

Thank you for completing the questions above, which make up the first part of the survey. You will receive an email with a link to complete the remainder of the survey from the study team soon. Please tell us more about the best way to reach you below.

What name do you prefer to be called?
What is the best day for us to reach you? Please select all that apply. £ Monday £Tuesday £Wednesday £Thursday £Friday £Saturday £Sunday £I don’t have a preferred day of the week
What is the best time for us to reach you on these days? As you respond to this question, please consider your local time zone. £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: _______________
What time zone are you 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:_________
What is your preferred email address? £I do not have a preferred email address. [PROGRAMMER: If this field is blank OR ‘I do not have a preferred email address’ is selected, skip to end of form and do NOT display gift card screen.]	What is a secondary email address that we could use if we can’t reach you at the first email? £I do not have a secondary email address.
We will reach out to you via email first. Do you have a phone number where we could contact you if we can’t reach you through email? £I do not have a phone number where the study team may reach me. (PROGRAMMER: If this field is blank OR ‘I do not have a phone number…’ is selected, skip to gift card information and end form.]
May we use this number to reach you by phone call, text message, or both? Please select all that apply. £Phone Call £Text Message	May we leave a voicemail message for you 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
Do you have a second phone number where we could contact you if needed? £I do not have a second phone number where the study team may reach me. [PROGRAMMER: If this field is blank OR ‘I do not have a second phone number…’ is selected, skip to gift card information and end form.]
May we use this number to reach you by phone call, text message, or both? Please select all that apply. £Phone Call £Text Message	May we leave a voicemail message for you 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

Thank you for answering these questions! To receive your $5 gift card, please click next below. Please remember to keep an eye on your email for your first survey invitation, which will come from (insert email address) within the next few days. As a reminder, you will receive an additional $10 gift card for completing the first survey, which will be sent to you by email in the next few days. You will also receive a $15 gift card when you complete the follow-up survey in about six months. Individuals selected to participate in interviews will receive an additional $30 gift card after completing their interview.

[PROGRAMMER: ADD FINAL DETAILS OF GIFT CARD REDEMPTION CODE, TO BE DISPLAYED ON THIS SCREEN].

If you are a participant working to complete this form with a staff person from your provider, please hand the device back to them at this time. If you are a staff person completing this form on behalf of a participant, please click next below to continue.

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Please click ‘Submit’ below to finalize this submission. Thank you for completing this form!