0 - National Criminal Justice Reference Service

Confidentiali@/Anonymitv
I understand that my identity will not be disclosed to anyone at any time for any burpose. I understand
that as a participant in this study, all information that I supply will be kept strictly confidential and
reviewed only by the investigators and their research assistants.
Disclaimer/Withdrawal
I understand that I am free to decide whether or not to participate in the study described above. I further
understand that non-participation in the research or withdrawal from the research will not affect my
treatment or any decision regarding my custody in any way. If at any time I should experience any
emotional distress as a result of participating in this study, I understand that I should contact my
treatment counselor (Drug and Alcohol Treatment Specialist) at once.
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Questions
I understand that I am encouraged by the investigator to ask questions at any time, and that my questions
will be given prompt and full answers. Questions may be directed to the Investigator at the address listed
on the front of this form, or to the Drug and Alcohol Treatment Supervisor who will direct them to the
Investigator. If I have any questions about my rights as a research subject, I may contact Ruth S. Smith,
Office of the Vice Provost for Research, Institutional Review Board, Temple University, N. Broad St.
and Oxford St., Philadelphia, PA, 191 22, phone (2 15) 204-7460.
This study has been explained to me. I have read the consent form, and I agree to participate. A
copy of this consent form will be retained in my treatment record.
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Participant’s Signature
Date
Witness’ Signature
Date
Investigator Signature
Date
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This document is a research report submitted to the U.S. Department of Justice. This report has not
been published by the Department. Opinions or points of view expressed are those of the author(s)
and do not necessarily reflect the official position or policies of the U.S. Department of Justice.