0930-0381 PATH _ Informed Consent

Attachment 3: Informed Consent

OMB No. 0930-0381

Expiration Date xx/xx/xxxx

Attachment 3.1: Informed Consent for Community Stakeholders

Informed Consent for Participation by Community Stakeholders in Projects for Assistance in Transition from Homelessness (PATH) Evaluation Discussions

1. You have been invited to participate in a PATH Site Visit conducted by the Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. The information we gather will be used to help develop a Site Visit Report on this state’s administration of the PATH program.

2. Your participation will involve sharing your thoughts and opinions on your experiences with homelessness, the PATH program and the mental health system. The amount of time involved in your participation will take no more than two hours.

3. There are no known risks associated with this activity.

4. The possible benefit to you from this study is that you will assist us in evaluating the effectiveness of a program designed to transition people from homelessness, with the possible outcome of improving these services for people who are homeless.

5. Your participation is voluntary, and you may choose not to participate in this activity or withdraw your consent at any time. You will NOT be penalized in any way if you choose not to participate or leave during the activity.

6. We will do everything we can to protect your privacy. Information is presented as a group response to questions. We may refer to your community, but we will not use your name unless you give consent specifically for that.

I have read this consent form and have been given the opportunity to ask questions. I will also be given a copy of this consent form for my records. I hereby consent to my participation in the activity described above.

Participant’s Signature Date

_________________________________________ ______________________

OMB No. 0930-03xx

Expiration Date xx/xx/xxxx

Attachment 3.2: Informed Consent for PATH Consumers

Informed Consent for Participation in a Focus Group for the Projects for Assistance in Transition from Homelessness (PATH)

1. You have been invited to participate in a focus group about PATH. A focus group brings together a small group of people to answer questions. This focus group is about the PATH program. The focus group is being organized by staff from the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA is the agency from the US Department of Health and Human Services that funds and monitors PATH. The information we gather will be used to help us improve the PATH program. If you decide to participate, you will be given a gift. You will receive the gift even if you change your mind and decide to not participate.

2. If you agree to participate in the focus group, you can share your thoughts and opinions about your experiences with homelessness, the PATH program, and the mental health system. The focus group will meet for two hours or less.

3. There are no known risks associated with this focus group.

4. If you participate in the focus group, you will be helping us understand the effectiveness of a program designed to transition people from homelessness. The information may help us improve the service for people who are homeless.

5. Your participation is voluntary, and you may choose not to participate in this activity. At any time, you can decide to leave the focus group.

6. We will do everything we can to protect your privacy. Information is presented as a group response to questions. We may refer to your community, but we will not use your name.

I have read this consent form and have been given the opportunity to ask questions. I will also be given a copy of this consent form for my records. I hereby consent to my participation in the activity described above.

Participant’s Signature Date