Informed Consent Form: PSAP Survey 

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Preparing for Success After Prison (PSAP) Program Evaluation

You are being asked to participate in an evaluation of the Preparing for Success After Prison (PSAP) program. You were selected as a possible participant in this evaluation because you have signed up to participate in the PSAP program. Your participation in the evaluation is VOLUNTARY. Thus, you may choose to not participate in the evaluation, and still participate in the PSAP program. Your participation in this evaluation will not affect your relationship with any criminal justice, treatment, parole/probation or other agency that you are or may become involved with. 

Why is this evaluation being done?

As part of the PSAP program we are conducting this evaluation to assess the impact that the PSAP program has on those participating in this program.  

What will happen if I take part in this evaluation?

If you volunteer to participate in this evaluation, we will ask that you complete two surveys that you will fill out on your own. The first survey will become available to you upon consenting to participate in this evaluation. The second survey will become available either upon completion of the PSAP program or three months later, depending on which comes first. Both surveys will include questions that assess levels of hope, self-efficacy, problem-solving skills, motivation to change, interpersonal trust, well-being, empathy, and emotional intelligence. The second survey will also ask you to provide feedback on the PSAP program.

How long will I be in this evaluation?

You will be enrolled in this evaluation for about 3 months and each survey will take approximately 15 to 30 minutes to complete. 

Are there any potential risks or discomforts that I can expect from this evaluation?

Although the risks associated with this study are minimal, it is possible that you may feel embarrassed or upset in response to some of the questions in the survey. If at any time you feel uncomfortable, you may simply choose not to answer those questions without any consequences to your participation in this evaluation. There is also minimal risk of the loss of data security and confidentiality but as described below in the confidentiality section the research team has taken several steps to prevent this from happening. 

Are there any potential benefits if I participate?

You will not directly benefit from your participation in this research study. However, the findings from this study may provide useful guidance about developing effective rehabilitative programming for women and men in criminal justice settings. 

Will I be paid for participating? 

You will not be paid for participating. 

Will information about me and my participation be kept confidential?

We are committed to ensuring the utmost confidentiality of your responses and will take all necessary measures to protect your data. All individuals involved in this evaluation have received training on maintaining confidentiality. None of the surveys you complete will include your name or any identifying information. Your survey responses will automatically be entered into a secured database platform maintained by Edovo after you submit the survey. Our evaluator, Dr. Stacy Calhoun from the University of California, Los Angeles, will receive de-identified survey responses for data analysis, meaning that she will not have access to any personal identifying information about you. Any data reported in publications or reports will be presented in aggregate form, further ensuring that individual participants cannot be identified.

What are my rights if I take part in this evaluation?

Your participation in this evaluation is voluntary. Your decision to participate or not participate in this evaluation will not affect your relationship with any criminal justice and/or treatment agency that you are or become involved with. You can leave at any time and you can refuse to answer any questions you don’t want to answer.

Who can I contact if I have questions about this evaluation? 

If you have any questions or concerns about the evaluation, please feel free to contact the Executive Director of the Prison Professors Charitable Corporation. His information is provided below:

NameContact number
Michael Santos[email protected]
Prison Professors 32565 Golden Lantern, Suite B1026
Dana Point, CA 92629
415-419-1728

To indicate your agreement to participate in the online survey, please proceed by clicking the “Consent” button to be taken to the first survey.

If you do not want to participate in the evaluation, please proceed by clicking the “Do Not Consent” button to be taken to the first module of the PSAP program. 

Survey: PSAP

Preparing for Success After Prison (PSAP) Program Survey

Background Information (Pre-Survey Only)

  1. Age: _____
  1. Which of the following best describes you?

☐ Hispanic or Latino ☐ American Indian or Native American 

☐ Black of African-American ☐ White and Non-Latino 

☐ Asian ☐ Other (Please Specify _________________________________) 

  1. What was your marital status prior to your incarceration (select one)?

☐ Never married ☐ Separated

☐ Living together ☐ Divorced

☐ Legally married ☐ Widowed

  1. What is your highest level of education (select one)?

☐ No High School ☐ Vocational certificate

☐ Some High School ☐ Some college

☐ High School Diploma ☐ Associate’s degree/Bachelor’s degree

☐ GED ☐ Master’s degree/doctorate degree

  1. If high school graduate, did you obtain your degree or GED in prison?

☐ Yes ☐ No ☐ Not applicable

  1. If any college, did you attend or obtain a degree in prison?

☐ Yes ☐ No ☐ Not applicable

  1. How many TIMES during your life have you been arrested? ___________ #ARRESTS
  1. How many TIMES during your life have you been arrested before the age of 18? ___________ #ARRESTS
  1. How many times have you been arrested for a property offense? ____________
  1. How many times have you been arrested for a violent offense? ____________
  1. How many times have you been arrested for a drug offense? ___________
  1. How many times have you been arrested for a sex offense? __________

SECTION A: Please indicate the extent to which you agree or disagree with the statements in this section 

Please answer all of the questions and remember that there are no right or wrong answers. When answering the questions, think about how you feel today.

1.I have close friends I can trust.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
2.I don’t really think about what I’m doing, I just do it.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
3.There are people who really understand me.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
4.My problems will dominate all of my life.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
5.I often do the first thing that comes into my head.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
6.There are people I can turn to when I have a problem.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
7.I tend to bounce back quickly after hard times.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
8.I make good decisions.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
9.I feel confident.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
10.I feel hopeless about my future.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
11.There are some people who I trust.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
12.I feel good about myself.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
13.I feel capable of making decisions.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
14.I have a hard time making it through stressful events.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
15.I owe it to myself to change.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
16.My life is full of problems which I can’t overcome.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
17.Anyone can talk about changing themselves; I’m actually going to do something about it.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
18.I often do things without thinking of the consequences.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
19.I usually deal with problems well.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
20.I am confident that I can cope with unexpected events.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
21.I am really working hard to change my life.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree

Section B: Using a scale from 0 to 4, please indicate how well each item describes you. 

 Does not describe me very well (0)      (1)      (2)     (3)  Describes me very well  (4) 
1. I sometimes try to understand my friends better by imagining how things look from their point of view.  [   ] [   ] [   ] [   ] [   ] 
2. I sometimes find it difficult to see things from the “other person’s” point of view.  [   ] [   ] [   ] [   ] [   ] 
3. Sometimes I don’t feel very sorry for other people when they are having problems.  [   ] [   ] [   ] [   ] [   ] 
4. I try to look at everybody’s side of a disagreement before I make a decision.  [   ] [   ] [   ] [   ] [   ] 
5. When I see someone being taken advantage of, I feel kind of protective towards him/her.  [   ] [   ] [   ] [   ] [   ] 
6. I often have tender, concerned feelings for people less fortunate than me.  [   ] [   ] [   ] [   ] [   ] 
7. Other people’s misfortunes do not usually disturb me a great deal.  [   ] [   ] [   ] [   ] [   ] 
8. If I’m sure I’m right about something, I don’t waste much time listening to other people’s arguments.  [   ] [   ] [   ] [   ] [   ] 
9. When I see someone being treated unfairly, I sometimes don’t feel sorry for them.  [   ] [   ] [   ] [   ] [   ] 
10. I am often quite touched by things that I see happen. [   ] [   ] [   ] [   ] [   ] 
11. I believe that there are two sides to every question and try to look at them both.  [   ] [   ] [   ] [   ] [   ] 
12. I would describe myself as a soft-hearted person.  [   ] [   ] [   ] [   ] [   ] 
13. When I’m upset at someone, I usually try to “put myself in his/her shoes” for a while.  [   ] [   ] [   ] [   ] [   ] 
14. Before criticizing somebody, I try to imagine how I would feel if I were in their place. [   ] [   ] [   ] [   ] [   ]

Section C: Using a scale from 1 to 5, please indicate the extent to which you agree with the following statements.

 Strongly disagree
(1
Disagree

(2
   Neither disagree or agree(3Agree  
(4)  
Strongly agree (5
1.  I know when to speak about my personal problems to others[   ] [   ] [   ] [   ] [   ] 
2.  When I am faced with obstacles, I remember times I faced similar obstacles and overcame them [   ] [   ] [   ] [   ] [   ] 
3.  I expect that I will do well on most things I try [   ] [   ] [   ] [   ] [   ] 
4.  Other people find it easy to confide in me [   ] [   ] [   ] [   ] [   ] 
5.  I find it hard to understand the non-verbal messages of other people* [   ] [   ] [   ] [   ] [   ] 
6.  Some of the major events of my life have led me to re-evaluate what is important and not important [   ] [   ] [   ] [   ] [   ] 
7.   When my mood changes, I see new possibilities[   ] [   ] [   ] [   ] [   ] 
8.  Emotions are one of the things that make my life worth living [   ] [   ] [   ] [   ] [   ] 
9.   I am aware of my emotions as I experience them [   ] [   ] [   ] [   ] [   ] 
10. I expect good things to happen[   ] [   ] [   ] [   ] [   ] 
11. I like to share my emotions with others [   ] [   ] [   ] [   ] [   ] 
12. When I experience a positive emotion, I know how to make it last[   ] [   ] [   ] [   ] [   ] 
13.  I arrange events others enjoy  [   ] [   ] [   ] [   ] [   ] 
14. I seek out activities that make me happy[   ] [   ] [   ] [   ] [   ]
15. I am aware of the non-verbal messages I send to others[   ] [   ] [   ] [   ] [   ]
16. I present myself in a way that makes a good impression on others[   ] [   ] [   ] [   ] [   ]
17. When I am in a positive mood, solving problems is easy for me[   ] [   ] [   ] [   ] [   ]
18. By looking at their facial expressions, I recognize the emotions people are experiencing[   ] [   ] [   ] [   ] [   ]
19. I know why my emotions change[   ] [   ] [   ] [   ] [   ]
20. When I am in a positive mood, I am able to come up with new ideas[   ] [   ] [   ] [   ] [   ]
21. I have control over my emotions[   ] [   ] [   ] [   ] [   ]
22. I easily recognize my emotions as I experience them[   ] [   ] [   ] [   ] [   ]
23. I motivate myself by imagining a good outcome to tasks I take on[   ] [   ] [   ] [   ] [   ]
24. I compliment others when they have done something well[   ] [   ] [   ] [   ] [   ]
25. I am aware of the non-verbal messages other people send[   ] [   ] [   ] [   ] [   ]
26. When another person tells me about an important event in his or her life, I almost feel as though I have experienced this event myself[   ] [   ] [   ] [   ] [   ]
27. When I feel a change in emotions, I tend to come up with new ideas[   ] [   ] [   ] [   ] [   ]
28. When I am faced with a challenge, I give up because I believe I will fail*[   ] [   ] [   ] [   ] [   ]
29. I know what other people are feeling just by looking at them[   ] [   ] [   ] [   ] [   ]
30. I help other people feel better when they are down[   ] [   ] [   ] [   ] [   ]
31. I use good moods to help myself keep trying in the face of obstacles[   ] [   ] [   ] [   ] [   ]
32. I can tell how people are feeling by listening to the tone of their voice[   ] [   ] [   ] [   ] [   ]
33. It is difficult for me to understand why people feel the way they do*[   ] [   ] [   ] [   ] [   ]

PSAP Participant Feedback Questions (Post-Survey Only)

  1. On a scale of 1 to 10, with 1 being “Very Poor,” and 10 being “Excellent,” how would you rate this program?

                        1 2 3 4 5 6 7 8 9 10

                 Very Poor                           Excellent

2.  Why did you give this rating?

3. Please tell us how this program has impacted you?

4.  What did you like best about this program and why?

5. What did you like least about this program and why?

6. Do you have any recommendations on how this program can be improved?

7.  Please provide any additional feedback here.

Program Participation (Post-Survey Only)

What other programs have you participated in since starting the PSAP Program?

 Name of Program Completed? (circle one)

____________________________________________               YES                   NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

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