Attachment B4 - HP Impact Survey Consent_Final

Attachment B4:

Health Professional Impact Survey Consent Form

JBS International, Inc. (JBS)

Informed Consent for Survey Participation

Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) Pediatric Mental Health Care Access (PMHCA) Program National Impact Study

Study Title: HRSA MCHB PMHCA Program National Impact Study

Researchers: HRSA MCHB funded JBS to conduct the Impact Study.

We (the study team) are inviting you to participate in a survey as part of research. This survey is completely voluntary. There are no negative consequences if you don’t want to take it. If you start the survey, you can always change your mind and stop at any time.

What is the purpose of this study? We want to understand how health professionals in HRSA’s PMHCA program screen, diagnose, treat, and refer children and adolescents who present with behavioral health concerns or issues. The information will be used to enhance our understanding of the PMHCA program—specifically, how the PMHCA program improves access to and receipt and utilization of behavioral health care and behavioral health-related impacts, as well as the program’s cost-benefit.

What will I do? This survey will ask questions about your screening, diagnosis, and referral of children and adolescents who present with behavioral health concerns or issues. It requests your first and last name and ZIP Code(s) to link your data with other data sources (i.e., Medicaid claims data). We are linking data solely for the purpose of identifying impacts of the PMHCA program on access to behavioral health care; you will not be individually evaluated. The survey will take 10 minutes or less to complete.

Risks:

• There are some questions you may not want to answer. You can skip them or quit the survey at any time.

• Personally identifiable information (name and ZIP Code[s]) will be collected; however, your name and ZIP Code(s) will only be used to identify your National Provider Identifier (NPI) and to link your survey responses to other data sources (i.e., Medicaid claims data). Neither your name, ZIP Code(s), or NPI will be shared with any other entity outside of the Impact Study staff.

• There are risks anytime you share information online. We’re minimizing this risk in the following ways:

  • We're using a secure system to collect these data.

  • We’ll store all data on a secure, password-protected server at JBS.

  • Data are stored with direct identifiers, but your identity will not be disclosed to anyone outside the research team.

Possible Benefits: There is no direct benefit to you because of participation. We hope the information learned from this study will improve the PMHCA program and ultimately improve access to behavioral health care for children and adolescents.

Estimated Number of Participants: Up to 21,070 health professionals will participate in the survey.

How long will it take? The survey will take 10 minutes or less to complete.

Costs: There are no costs to you to participate other than the time it takes for you to complete the survey.

Future Research: We will share de-identified data (all identifying information removed) with HRSA. No future research studies are currently planned.

Funding Source: HRSA MCHB is funding this study.

Confidentiality and Data Security:

We’ll collect the following identifying information for the research:

• First and last name

• Primary, secondary, and tertiary practice ZIP Code(s)

• Email address

This information is necessary for survey administration and tracking, as well as for linking your data with other data sources (i.e., Medicaid claims data).

Where will data be stored? The data will be stored on a secure, password-protected server at JBS. If applicable, hard copies will be stored in a locked file cabinet in the office of the Project Director at JBS.

How long will it be kept? The data will be kept for 10 years.

Who can see my data?

• We will have access to your data to analyze the data and to conduct the study.

• We may share our findings in reports or presentations. If we do, the results will be grouped data, with no individual results or identifying information.

• Agencies that enforce legal and ethical guidelines, such as

  • The Institutional Review Board (IRB) at JBS

  • The Office for Human Research Protections (OHRP)

Questions About the Research, Complaints, or Problems: For questions about the study or if you have problems or concerns, contact Amanda Gmyrek by email ([email protected]) or by phone (240-645-4848).

Questions about your rights as a research participant, complaints, or problems: Contact the JBS Institutional Review Board (IRB) at [email protected] or [email protected]

Please print or save this screen if you want to be able to access the information later.

IRB #: AG23-01

IRB Approval Date: January 8, 2024

Agreement to Participate:

Your participation is completely voluntary, and you can withdraw at any time.

To take this survey, you must be:

• At least 18 years old

• A health professional

If you meet these criteria and would like to take the survey, please consent to participating by signing your name below, then click the next button below to start the survey. Remember, your participation is completely voluntary, and you’re free to withdraw from the study at any time.

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