INFORMED ASSENT TO PARTICIPATE IN A
SELF-SCREENING
AND SELF-REFERRAL PREVETION SERVICE AND SHARE ANNONYMOUSLY
(11/23/21 DRAFT at Flesch-Kincaid Reading Level 6.8)
What is the S4S? Screen for Success (S4S) asks questions about your feelings and behaviors. These questions are related to your wellness, family, health, mental health, and substance use. You received a link to the screener from your parents, caregivers, or another adult. If the S4S finds any problems, the screener will help you find services near you that may help.
What happens after I finish the screener? When you finish the S4S, the app will generate a report to show your strengths and problems. It will also help you find nearby services that may help you with your problems.
Are there any benefits to taking the S4S? Taking the S4S can help you and your family identify and describe your needs. The report can help connect you to services. It is free, and your participation may help us to improve our service. Sharing your data may also help us improve the service for others.
Will anyone else see my answers? It is up to you. If you select “yes” to the first question below, the person who asked you to do the screener will receive a copy of your answers and report. If you select “no,” your information will be visible only to you. We allow you to add your name before printing the report. We do not save names. S4S staff and other researchers would like to use your answers to improve our services. S4S would remove your username before using or sharing the data. We will ask you separately about this. When you finish the screener, we will check if you want to change your answers to either question.
Are there any risk to taking S4S? There are few risks to taking the screener. You may feel uncomfortable answering some of the quesitons and sharing the answers with others. S4S will not share the answers without your permission. S4S staff and other researchers will not know who you are and will only report answers across groups of people. It is not usually a problem, but there is always a risk that someone could gain access to the data. We try to prevent this by storing all data on a secure server. Your username and any contact information are for you to track changes over time. They will not be exported or shared. After 2 years, we will destroy all information that identifies you. Federal law also protects your privacy.
Is answering the S4S voluntary? You are free to say no. You can also skip any question. Services in the community do NOT require you to participate. It is up to you whether to share your answers and report with the person who sent you the invitation. It is also up to you whether you want to share your data with S4S staff or researchers. If you decline to share your data, you can still save the results and access the resources. You can also change your mind about sharing at any time.
What if I have more questions? You can send your questions to the S4S team by calling/texting 309-000-0000 or emailing [email protected]. You can also send any questions to the S4S project director (Dr. Michael Dennis; phone: 309-451-7801; email: [email protected]). If you have a question about your rights please call Dr. Ralph Weisheit at (309) 451-7855. He is the chair of Chestnut’s Institutional Review Board for the protection of Human Participants. You can save a copy of this document by clicking here.
YOUTH
AGREEMENT (ASSENT) TO PARTICIPATE IN THIS SERVICE.
I
understand what the S4S does and how researchers may use the data. I
have information about how ask questions about the S4S. I know I do
not have to use the S4S or stop using it at any point. I know that my
answers to my S4S will be private according to federal law. When
required by law, suitable government agencies may review the
anonymous results of the S4S screener. Please answer the following
yes or no questions, and sign at the bottom.
May we share your answers and report (including your name) with your parent or other person who referred you? (Check one) Yes No
May we and other researchers use your answers “without your name or username” (anonymously) to help improve this and other services? (Check one) Yes No
Name of Participant (electronic signature): ___________________________________ Date ____________
Date of Birth _______________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | TIMELINE FOLLOWBACK CALENDAR: 2010—I assume the care manager will do this every 3 months |
| Author | ldillenb |
| File Modified | 0000-00-00 |
| File Created | 2022-07-11 |