Consent to Participate in an Evaluation Study
Screening, Brief Intervention, Referral and Treatment (SBIRT) Patient Survey Consent
You are being asked to participate in an evaluation study. Before you decide if you want to take part in this study, please read this informed consent form so that you understand what the study is about and what you will be asked to do. This form also tells you who can be in the study, the risks and benefits of the study, how we will protect your information, and who you can call if you have questions. Please ask the interviewer to explain anything you don’t understand before you make your decision.
RTI International, a private research firm based in Research Triangle Park, North Carolina, is currently conducting an evaluation of the Screening, Brief Intervention, Referral and Treatment (SBIRT) program designed to help expand care for substance use and misuse. The SBIRT program includes screening, brief intervention, brief treatment, and referrals for persons at risk for dependence on alcohol or drugs. This survey is sponsored by the Department of Health and Human Services and is conducted in collaboration with this facility. We are asking you as a patient of this facility to participate in this important confidential survey.
You will be asked questions about your background (e.g., age, gender, ethnicity, employment); health and health care; problems and feelings experienced during the past month; tobacco, alcohol, and other drug use; and attitudes about tobacco, alcohol, and drug use. As a participant, you will be asked to complete this survey at this time and on one other occasion in the next 6 months.
Completing the survey process will take about 25-28 minutes today and on the next occasion within the next 6 months, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
In completing this survey, you may feel a little uncomfortable about some of the questions. At any point, you may choose to refuse to answer any question that may make you uncomfortable.
The information collected in this study will help us gain knowledge about substance use care and prevention programs.
You will receive $5 cash for being willing to complete the survey. You may keep the $5 even if you refuse to answer any or all of the questions.
All the information you provide in this survey will be kept strictly confidential and will not be shared with anyone from this facility. RTI will not have access to your name and will not be able to connect your survey responses to your name. The information will not be shared with anyone outside of those involved with this study. Information from this study may be given to persons or companies that are contracted by the sponsor to have access to the information during and after the study. However, findings will be summarized in group form only. Many precautions have been taken to protect your information. Your name will be replaced with a number. Other personal information like your address and Social Security Number will be stored separately from the answers you provide on the questionnaires. If the results of this study are presented at scientific meetings or published in scientific journals, no information will be included that could identify you or your answers personally.
We will contact you within the next 6 months to ask you to participate in a short follow-up survey. You will be able to make a decision at that time about participating. Your participation is completely voluntary.
Your decision to take part in this evaluation study is completely voluntary. You can refuse any part of the study and you can stop participating at any time. You can refuse to answer any question. If you decide to participate and later change your mind, you will not be contacted again or asked for further information.
If you have any questions about the study, you may call (project team member’s name and toll-free telephone number). If you have any questions about your rights as a study participant, you may call (IRB contact person).
Your signature below indicates that you have read (or been read) the information provided above, have received answers to your questions, and have freely decided to participate. By agreeing to participate in this evaluation, you are not giving up any of your legal rights.
Date Signature or Mark of Participant
Printed Name of Participant
I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this evaluation have been explained to the above-named individual.
Date Signature of Person Obtaining Consent
Printed Name of Person Obtaining Consent
| File Type | application/msword |
| File Title | APPENDIX 4: |
| Author | proth |
| Last Modified By | proth |
| File Modified | 2006-06-28 |
| File Created | 2006-05-11 |