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pdfAttachment A
Federal Wide Assurance
Office for Human Research Protections Database
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IRB Organization Information
IORG0000380 - Research Triangle Inst (RTI
International) (Active)
Located at: Research Triangle Park, NORTH CAROLINA
Expires: 01/31/2014
IRBs for this Organization: 3
Agency Only Access
IRB#
IRB Name City
State/Country
Status IRB Type
IRB00000653 Research
Triangle
Inst IRB
#1
Research
Triangle
Park
NORTH
CAROLINA
Active
OHRP/FDA
IRB00000654 Research
Triangle
Inst IRB
#2
Research
Triangle
Park
NORTH
CAROLINA
Active
OHRP/FDA
IRB00000655 Research
Triangle
Inst IRB
#3
Research
Triangle
Park
NORTH
CAROLINA
Active
OHRP/FDA
Department of Health and Human Services (DHHS) | Office for Human Research Protections (OHRP)
http://ohrp.cit.nih.gov/search/IOrgDtl.aspx
4/20/2011
Attachment C
2013 Quality Control Form
VERSIÓN EN ESPAÑOL AL REVERSO
NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 2 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer,
Paperwork Reduction Project (xxxx-xxxx); Room 8-1099; 1 Choke Cherry Road, Rockville, MD 20857. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is xxxx-xxxx.
OMB No.: xxxx-xxxx
OMB Expiration Date:
xx-xx-xx
QUALITY CONTROL FORM
As part of our quality control program, we plan to contact a portion of the survey participants to
make sure that the interviewer has followed the study procedures. We only ask general
questions—no specific information is required. We sincerely appreciate your cooperation.
Please fill in the boxes below. (PLEASE PRINT CLEARLY.) Thank you.
[Your phone number will be kept confidential and will not be released to anyone other than our
quality control representatives.]
TELEPHONE
NUMBER
_
_
(Area Code)
(Telephone Number)
YOUR
ADDRESS
CITY
ZIP
CODE
STATE
BOXES BELOW MUST FIRST BE COMPLETED [IN INK] BY INTERVIEWER.
TODAY’S
DATE
M
M
_
D
D
_
1
FI
NAME
CASE
ID #
3
TIME
.
.
AM
PM
FI
ID #
_
_
_
Include
A or B!
IF respondent is 12 - 17 years old, which
adult granted permission for the interview?
(Examples: father, mother, etc.)
[Print Parent/Guardian’s relationship to the child in this box.]
Attachment D
2013 Lead Letter
DEPARTMENT OF HEALTH & HUMAN SERVICES
U.S. Public Health Service
Center for Behavioral Health Statistics and Quality
Rockville, MD 20857
______________, 2013
Dear Resident:
To better serve all people across the nation, the United States Public Health Service (USPHS)
is conducting a national study on health-related issues. Your address was randomly chosen
along with more than 200,000 others. Research Triangle Institute (RTI) is under contract to
carry out this study for the USPHS. Soon, an RTI interviewer will be in your neighborhood to
give you more information.
When the interviewer arrives, please ask to see his or her personal identification card. An
example of the ID card is shown below. The interviewer will ask you a few questions, and
then may ask one or two members of your household to complete an interview. It is possible
that no one from your household will be chosen to be interviewed. You may choose not to
take part in this study, but no one else can take your place. Every person who is chosen and
completes the interview will receive $30 in cash.
All the information collected is confidential and will be used only for statistical purposes.
This is assured by federal law. This letter is addressed to “Resident” because your address was
selected, and we do not know your name. Feel free to ask the interviewer any questions you
have about the study.
Your help is very important to this study’s success. Thank you for your cooperation.
Ilona S. Johnson
National Field Director, RTI
(800) 848-4079
pl
m
Ex
a
Joel Kennet, Ph.D.
National Study Director,
Center for Behavioral Health Statistics
and Quality
e
Sincerely,
______________________________
Assigned Field Interviewer
Confidentiality protected by the Confidential Information Protection and Statistical Efficiency Act of 2002 (PL 107-347)
Authorized by Section 505 of the Public Health Service Act (42 USC 290aa4)
Approved by Office of Management and Budget (OMB Approval No. xxxx-xxxx)
Attachment E
2013 Contact Cards
Sorry II
Missed You…
Research Triangle Institute (RTI)
Research Triangle Park, NC 27709-2194
Sorry II
Missed You…
Research Triangle Institute (RTI)
Research Triangle Park, NC 27709-2194
Dear Resident:
Dear Resident:
I stopped by today to talk to you about an
important research study being conducted by RTI.
I stopped by today to talk to you about an
important research study being conducted by RTI.
I am sorry that I did not find you at home. I will
return to talk with you in the next few days.
I am sorry that I did not find you at home. I will
return to talk with you in the next few days.
Thank you in advance for your participation.
Thank you in advance for your participation.
Sincerely,__________________________________
Sincerely,__________________________________
Date: ________________ Time: ______________
Date: ________________ Time: ______________
Attachment L
2013 Quality Control Letter
NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 4 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, Paperwork Reduction Project (xxxx-xxxx); Room 8-1099; 1
Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx.
RESIDENT
[ADDRESS]
OMB No.: xxxx-xxxx
OMB Expiration Date:
xx/xx/xx
[DATE]
RTI has been conducting a nationwide survey for the United States Public Health Service on tobacco, alcohol, drug
use and other health-related issues. Our records indicate that a [AGE] year old [GENDER] in your household was
interviewed. We would appreciate it if [HE/SHE] would take a moment to complete the following questions about
[HIS/HER] experience.
This information is only used to verify the quality of our interviewer’s performance.
1. Were you interviewed in-person or over the telephone?
In-person ___ Over the telephone___
2. Did the interviewer provide you with a laptop computer for you to enter some of your responses?
Yes___
No___
Please explain:_________________________________________________________________
3. Did you complete a computer practice session that showed you how to enter your responses in the computer?
Yes___ No___
4. Did you have the option of listening to the questions through a set of headphones?
Yes___ No___
5. Were you paid for your participation?
Yes___ No___
If yes, how much were you paid? $_____
6. Was the interviewer professional and courteous?
Yes___
No___
Please describe how our interviewer could improve his/her behavior: _____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
A stamped, pre-addressed envelope is enclosed for your convenience in returning this form. Thank you for your
cooperation.
Sincerely,
Ilona S. Johnson
National Field Director
| File Type | application/pdf |
| Author | lchilds |
| File Modified | 2012-05-24 |
| File Created | 2012-05-24 |