Screening, Brief Intervention, Referral and Treatment (SBIRT) Practitioner Survey Verbal Consent to Participate in Research
Hello, my name is ______________ and I work for RTI International. I would like to talk to you about participating in an evaluation study. Before you decide if you want to take part in this study, I need to read this consent form to you 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 me to explain anything you don’t understand before you make your decision.
RTI International 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 staff member of this facility to participate in this important anonymous survey.
You will be asked questions about your background, work environment, and your experiences with the SBIRT program. As a participant, you will be asked to complete this survey at this time. Completing the survey will only take about 24 minutes today, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. There is a very important benefit to the study in that it will help us to gain knowledge about substance use care and prevention programs.
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 be documenting your name and will not be able to connect your survey responses to your name. At no time will your employer or anyone else not connected with the research see your responses. 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.
Your decision to take part in this evaluation study and your participation 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 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).
By verbally agreeing to participate in this evaluation, you are not giving up any of your legal rights. Verbally agreeing to participate indicates that you have been read the information provided above, have received answers to your questions, and have freely decided to participate. Do you give your verbal consent to participate in this evaluation?
Date Yes—Participant Agrees
No—Participant Does Not Agree
I certify that the nature and purpose, 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 7: |
| Author | proth |
| Last Modified By | proth |
| File Modified | 2006-06-28 |
| File Created | 2006-05-11 |