National Patient Letter

G eorge E. Wahlen

Department of Veterans Affairs Medical Center

VA Salt Lake City Health Care System

500 Foothill Drive

Salt Lake City, UT 84148

January 30, 2021

Consent and Authorization Cover Letter

Assessing VHA Patient and Provider Perceptions of Point-of-Care Research

Dear Veteran,

I am writing to invite you to participate in a study for veterans who get their care at the Salt Lake City VA Medical Center. The Veterans Health Administration is interested in understanding patient’s perceptions of a new research program called Point-of-Care research. The purpose of this study is to evaluate this program.

I am asking you to fill out a survey. If you choose to answer the questionnaire online, the link is provided below. Just type the link into your browser.

If you want to answer it on paper, please return the completed questionnaire in the enclosed, self-addressed stamped envelope. Answers will be kept secret. Once the questionnaires are collected, all links to personal health information will be destroyed.

There are no direct benefits for you, but we hope the information from this study will help doctors provide the best clinical care for veterans. The risks to participating are loss of time and minimal risk of loss of privacy.

If you have questions, complaints, or concerns about this study, or if you think you may have been harmed from being in this study, you can contact the Principal Investigator, Charlene Weir, PhD, from the Salt Lake City VA IDEAS Center at (801) 582-1565, ext.4-5114 or [email protected].

Contact the Institutional Review Board (IRB) if you have questions regarding your rights as a research participant. Also, contact the IRB if you have questions, complaints or concerns which you do not feel you can discuss with the investigator. The University of Utah IRB may be reached by phone at (801) 581-3655 or by e-mail at [email protected].

It should take 15 minutes to complete the questionnaire. Participation in this study is voluntary. You can choose not to take part. You can choose not to finish the questionnaire or omit any question you prefer not to answer without penalty or loss of benefits. By returning this questionnaire, you are giving your consent and authorization to participate and allow us to use information from your medical record, as described below.

Authorization for Use of Your Protected Health Information

Participating in this study means you allow us, the researchers in this study, and others working with us to use information about your health for this research study. You can choose whether you will participate in this research study. However, in order to participate you have to agree to participate according to the instructions in this consent and authorization form.

This is the information we will use is your:

• Name

• Age

• Diagnoses

• Service connectedness

• Number of times you visited a VA clinic in the past year

• Number times you were in the VA hospital in the past year

Others who will have access to your information for this research project are the University’s Institutional Review Board (the committee that oversees research studying people) and authorized members of the study research team, who need the information to perform their duties to ensure integrity of the research.

You may revoke this authorization. This must be done in writing. You must either give your revocation in person to the Principal Investigator or the Principal Investigator’s staff, or mail it to Charlene Weir at 500 Foothill Drive, Mail stop #182, Salt Lake City, UT, 84148. If you revoke this authorization, we will not be able to collect new information about you, and you will be withdrawn from the research study. However, we can continue to use information we have already started to use in our research, as needed to maintain the integrity of the research.

You have a right to information used to make decisions about your health care. However, your information from this study will not be available during the study; it will be available after the study is finished.

This authorization lasts until this study is finished.

By answering this questionnaire, you are giving your consent to participate.

Thank you for considering this opportunity. I appreciate your assistance.

Charlene R. Weir, PhD, RN
Associate Director, Salt Lake IDEAS Center

Footer for IRB Use Only Version: 112011

University of Utah Institutional Review Board Approved 5/2/2012 Expires 5/1/2013 IRB_00055833