NWIL GPRA Consent Form
Evaluation Consent Form
Evaluation of State Opioid Response Grant
Principal Investigator:Kelsey Smith Payne,BA, CADCII, QMHA, Opioid Grant Coordinator, Behavioral Health Unit,Oregon Health Authority,(503)856-2785 Co-Principal Investigator: Lauren Maxim, PhD, RMC Research Corporation, (503) 223-8248, ext. 5740 Sponsor: U.S. Department of Health and Human Services, Substance Abuse Mental Health Services Administration
Purpose
You are invited to participate in this evaluation because you get services from a program that participates in a grant to increase access to medication assisted treatment or recovery support services for people with opioid use disorder and to reduce opioid-related overdose deaths. The purpose is to see how effective these program services are. Being in this evaluation will last until you are discharged from the program.
What will happen if I decide to participate?
If you agree to participate, you will be asked to take part in 3 interviews. The interviews ask how services have affected your drug and alcohol use, mental health, physical health,education,employment status, legal problems, relationships, and living conditions.You will be asked to give program staff your contact information to help them get in touch with you for the follow-up interviews.Your participation in this evaluation does not affect services you get here. You may continue to participate in interviews even if you stop getting services here.
How long will I be in this evaluation?
The first interview will take place during your intake assessment. After 6 months, you will be asked to do a 2nd interview. The 3rd interview happens when you leave the program. Each interview is 30 to 45 minutes
What are the risks or side affects of participation?
Some interview questions may seem personal or may upset you. You may refuse to answer any questions that you do not wish to answer. You may also stop the interview at any time. If you get so upset by the questions that you appear to need counseling, one of the counselors will speak with you.There is also a small risk that your private information might be accidentally revealed, but we have taken many steps to keep this from happening (see “How will my information be kept confidential?” below)
What are the benefits to participation?
There are no direct personal benefits from being in this evaluation. However, your participation may contribute new information about services which could benefit future clients seeking treatment for opioid use disorder.
What are the alternatives to participation
You may choose not to participate in this evaluation. If you do take part, you may refuse to answer any question asked or choose not to do some activities. You may stop taking part in the evaluation at anytime. Your choice will not change the treatment you get here.
How will my information be kept confidential?
Your privacy is important to us. To protect your privacy: We won’t tell anyone if you take part in the evaluation or not.Interviews will happen in a private place, where no one can overhear you.Your name and what you tell us will be kept confidential, to the extent allowed by law. (By “kept confidential,” we mean the names of people who participate will not be given to anyone else.We share your responses in a way where no one can ever guess or know what you said.)If the interviewer learns from you that you might try to harm yourself or others, or that you might be involved in child abuse or elder abuse,that information must be reported to appropriate authorities.We take steps to protect the security of all your personal information, but we cannot guarantee confidentiality of all data. Your name will not be used in any publications or reports. Only data combined from all participants will be shared. Personal information (such as your name and other identifying information) will be stored by the program and is not shared with evaluators. Evaluators store information in a locked file cabinet and in password-protected computer files to protect your information.
How long will my information be kept?
Evaluators store electronic data on our secure server during the evaluation and for 2 years after the evaluation ends. After that, data will be removed from the server and saved on DVDs which are stored in locked filing cabinets in a secure room only accessible to evaluation staff for a period of 5 additional years. At that time, the DVD will be destroyed by a professional document shredding company that provides certification that the DVD is destroyed
Will I be paid for taking part in this evaluation?
You will receive a $30 gift card for the 2nd interview that you complete 6 months after starting services as a way of thanking you for your time.
Can I stop participating once I start?
Yes. Your participation in this evaluation is completely voluntary. You can choose not to participate in the evaluation. You can start and decide to stop at any time without a penalty or change in your services here. Your decision to participate, or to stop participating,will not affect your relationship with the program.You can stop participating by telling program staff you no longer want to participate.If you choose to stop participating in the interviews,the evaluation will continue to use the information from your previous interviews unless you tell us you don’t want us to do so.
Whom can I call with questions or concerns about this evaluation?
Lauren Maxim at RMC Research Corporation can be reached atlmaxim@rmcres.comor (800) 788-1887,ext. 5740 to answer questions or concerns you may have about this evaluation. You can also contact Solutions IRB at 1-855-226-4472 or at participants@solutionsIRB.com
Consent: This is a consent form. Your signature below means: (check after reading)
You have read and understand what this form says.
You are willing to take part in the evaluation.
You know that you do not have to participate. And even if you agree, you can change your mind at any time.
Your decision to participate has nothing to do with the services you receive here
You will get a copy of this form you keep.
Your signature below shows that you have read this information. You agree to participate in this evaluation.
Signature of Interview Participant
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Signature of Data Collector
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