National Clas Standards Evaluation Informed Consent for Staff Survey

National CLAS Standards Evaluation Informed Consent Form – Survey

FORM APPROVED

OMB No: 0990-XXXX

Expires: MM/DD/YYYY

Evaluation of HHS Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care in Health and Health Care Organizations

INFORMED CONSENT FORM

PURPOSE
The Office of Minority Health (OMH) at the Department of Health and Human Services (HHS) is working to understand how its National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, or the National CLAS Standards, National CLAS Standards, are understood, adopted, and implemented in health and health care organizations across the country. As part of this evaluation project, we are administering surveys to the staff of select health and health care organizations across the country. The survey will take approximately 30 minutes.

RISKS
There are no foreseeable risks for participating in this research.

BENEFITS
While there are no direct benefits to you, by taking part in this project, you have the opportunity to help the HHS Office of Minority Health understand better how health and health care professionals and organizations become aware of, gain knowledge about, adopt, and implement the National CLAS Standards.

CONFIDENTIALITY
The data in this study will be confidential. Everything you tell us will remain anonymous. We will not use your name or other identifying information in any materials that result from this project. Names and other personally identifiable information will not be placed on surveys or associated with other research data. For coded identifiable data (such as sex, race, ethnicity, name of organization), participants’ individual names will not be included on surveys or associated with other research data. A unique code will be used as an anonymous identifier, and applied to each survey using an identification key, which will be kept separate and secured from the survey responses. A unique benefit of your participation in this project is that your organization may receive an aggregate summary of responses submitted by staff from your organization that complete this survey, which may be useful to your organization as it assesses and monitors its policies and procedures. All data will be reported as overall summaries without individual or organizational identification.

PARTICIPATION
Your participation is voluntary, and you may withdraw from the evaluation project at any time and for any reason. If you decide not to participate or if you withdraw from the project, there is no penalty or loss of benefits to which you are otherwise entitled. There are no costs to you or any other party.

CONTACT
This evaluation project is being conducted by the Health Determinants & Disparities Practice at SRA International, Inc. and Rodney Hopson, College of Education and Human Development, Division of Educational Psychology, Research Methods, and Education Policy at George Mason University. Staff in the Health Determinants & Disparities Practice at SRA International may be reached at 240-514-2991 for questions or to report an evaluation-project related problem. You may contact the George Mason University Office of Research Integrity and Assurance at 703-993-4121 if you have questions or comments regarding your rights as a participant in this project.

This research has been reviewed according to George Mason University procedures governing your participation in this research.

CONSENT
I have read and understand the information regarding my participation in this survey about the HHS OMH’s National CLAS Standards, all of my questions have been answered by the research staff, and I agree to participate in this study.

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Date of Signature