Page 131 - Preventing Youth Violence

APPENDIX IX

CSJP Informed Consent Form – Case Study

You have the right to be adequately informed of your rights and responsibilities. This form tells you
about these rights and responsibilities for the purpose of this interview. Please read the following
carefully, and then sign, showing that you understand and agree with what is said in this form.

The Interviewer
I am a Consultant with the Ministry of National Security. I am conducting a case study with a CSJP

Client. The results from this case study will assist the CSJP with making further informed decisions
about its interventions with at-risk youth and adults. It is also the intention of the CSJP to publish
information about this case study. Your participation is completely voluntary and you are free to
withdraw at any point, without penalty.

The Interviewee
Throughout the interview, confidentiality is maintained for the interviewee. This standard

procedure and practice is for all interviewees, regardless of age or background, except in the
following circumstances:
a) You instruct me to tell someone else and provide written permission of this.
b) I determine you are a danger to yourself (e.g. self-harm or suicide), to others or
someone is a danger to you.
c) I am ordered by a court to disclose information.
d) The law is going to be, or has been, broken.
e) Abuse of children is a mandatory reporting offence which I am bound by law to
report.

f) For supervision and education purposes (basic information only is shared in this
instance, not names or details that would in any way disclose or identify you, the client).

Where confidentiality cannot be maintained, as the interviewer I will take all steps possible to
inform/discuss my intention with you.

Your signature on this document indicates that you have read and understood this statement,

and any questions you have about this statement have been answered to your satisfaction.

Name of Interviewee:_________________________________ Signature: ______________Date:__________

Name of Interviewer:__________________________________Signature: ______________Date:__________

105