HBCU consent form

Informed Consent Form

Survey of Historically Black Colleges and Universities (HBCUs) Engagement to Eliminate Health Disparities Consent Form

Purpose

The American Institutes for Research (AIR) has been contracted by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HHS/HRSA), Office of Minority Health to conduct an assessment of the engagement of Historically Black Colleges and Universities (HBCUs) in campus and community-based activities designed to eliminate health disparities among African Americans.

As part of this study you are being asked to complete a short online survey designed to gather information about the types of activities conducted by faculty and students to help eliminated health discrepancy. Specifically, we are interested in learning about the factors that have helped you, faculty, and students on your campus implement activities in each of the following areas:

• research and scholarship;

• research infrastructure development;

• campus-based programs aimed at students and/or employees; and

• community outreach and services implemented by HBCU faculty and students.

Completion of the online survey is entirely voluntary. At any time you may ask to have your online survey withdrawn from the study and you may choose to discontinue your participation in the online survey without penalty.

Risks and Discomfort

No risks are anticipated as result of participation in the online survey.

Benefits

You have been asked to participate in this study because of your depth of knowledge of campus-based policies and initiatives that can potentially foster the development of activities focused on the elimination of health disparities. The information you provide will allow AIR and the HHS/HRSA Office of Minority Health to assess the activities to eliminate health disparities presently being carried out on HBCU campuses and in surrounding communities. The information will also be used to develop technical assistance to assist other HBCUs in the implementation of similar activities designed to eliminate health disparities.

Confidentiality

All survey information will be protected and will be used for research purposes only by the Department of Health and Human Service, Office of Minority Health and the AIR research team. Anonymity is assured, as neither your name nor the name of your institution will appear on the online survey or in any written reports that stem from data collected through the online survey. This consent form is not attached to the online survey and will not be used to identify or track your contributions to the online survey.

More Information

If you have questions about this study please contact Dr. Carmen Arroyo at (202) 403-5904. For questions regarding your rights as a human subject participating in this research, contact Doug Gibson at (202) 342-5052.

Informed Consent

If you have read and understood the information above and agree to voluntarily participate in this research please sign below.

Print Name: __________________________________________________________

First Last

Signature: _____________________________________Date___________________

College/University: ____________________________________________________

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