Consent Form
HCBS Experience Survey
We are asking you to be in a research study. You do not have to be in the study. If you say yes, you can quit the study at any time. Please take as much time as you need to make your choice. Your services and supports will not change in any way if you say no. |
Why are you doing this research study?
We want to learn more about how to help people with disabilities who receive services in their homes. This study will help us learn more about these services. We are asking people like you who have disabilities to help us.
What happens if I say yes, I want to be in the study?
If you say yes, we will:
• Ask about the people paid to help you, your case manager, your personal safety, your transportation services, things you do in the community, and about working at a job.
• Read the questions out loud and enter your answers into a computer.
There are no right or wrong answers to these questions. You can skip any question you do not want to answer.
How long will the study take?
The study will take about 30 minutes of your time.
What happens if I say no, I do not want to be in the study?
No one will treat you differently. You will not be penalized. The services and supports you get will not change.
What happens if I say yes, but change my mind later?
You can stop being in the study at any time. You will not be penalized. The services and supports you get will not change.
Who will see my answers?
The only people allowed to see your answers will be the people who work on the study and people who make sure we run our study the right way.
We will not put your individual answers into your medical record. When we share the results of the study we will not include your name. We will do our best to make sure no one outside the study will know you are a part of the study.
None of the people who help you will know what you say, unless you want them in the room while you answer the questions. All information provided will remain private under the Privacy Act. Your answers will be grouped with others and will be reported with no identifying information.
Will it cost me anything to be in the study?
No.
Will being in this study help me in any way?
Being in the study will not help you, but may help people with disabilities in the future.
Is there any way being in this study could be bad for me?
There is a chance that the questions could make you sad or upset.
What if I have questions?
Please call your state contact person at [insert phone #] if you have any questions about the study.
You can also call, [IRB, contact name, and phone number] if you:
• Have questions about your rights.
• Feel you have been injured in any way by being in this study.
Do I have to give consent?
No. You only give your consent if you want to be in the study.
What should I do if I want to be in the study?
If you are selected to complete the survey over the phone, you will need to give verbal consent at the time of the interview. If you are asked to complete an in-person interview, your interviewer will give you a consent form to sign. By verbally agreeing over the phone or by signing the consent form you are saying:
• You agree to be in the study.
• We talked with you about the survey information and answered all your questions.
You know that:
• You can skip questions you do not want to answer.
• You can stop answering our questions at any time and nothing will happen to you.
• You can call [state’s name, contact name, and phone number] if you have any questions about the survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | u0163045 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |