INFORMED CONSENT TO PARTICIPATE AND AUTHORIZATION FOR RESEARCH

Title of Research Study: Provider Membership Survey: #185

The National Center on Addiction and Substance Abuse (CASA) at Columbia University is conducting a study of the substance abuse treatment system as it currently operates throughout the United States. The goal of this study is to provide a blueprint for building a sound infrastructure to address the public health problem of addiction in this country. As part of our study, we would like to gain insight into the beliefs about the substance abuse treatment system held by treatment providers.

Please read and think about the information in this document which will tell you about the purpose, risks and benefits of this brief survey so that you can decide whether or not you want to participate. Participation is voluntary. If you agree to participate after reading this document, please check the “I AGREE TO PARTICIPATE” box that appears on the next page, and then proceed to complete the anonymous survey.

What is the purpose of this survey?
As part of a larger study of the substance abuse treatment system in the United States, CASA is interested in learning about the perspectives and experiences of individuals who provide treatment for addiction to drugs or alcohol.

How will the data be used?
Your responses will be combined with those of the other respondents to this survey and CASA statisticians will examine the data to explore patterns that emerge about the treatment process. The findings of these analyses will be included in a larger report of CASA’s national study of the treatment system. The information only will be reported as averages or as totals from the group as a whole; your individual responses will not be reported and none of the information you provide will be connected in any way to your name or any other information that might allow someone to identify you as the respondent.

What are the risks of this study?
It is possible that responding to this survey might elicit some unpleasant memories or emotional responses. While you are completing the survey, you may skip any questions that are difficult for you to respond to or discontinue your participation.

What are there benefits of taking part in this study?
There are no direct benefits to you personally for participating in this survey. The primary benefits from this work are for the advancement of our understanding of the treatment system and how best to help people suffering from substance abuse and addiction.

Will I receive any payment or other compensation for my participation?
No.

What about confidentiality?
Your responses to this survey will be anonymous. The results of the survey may be published for scientific purposes, but will not include your name or any other identifiable references to you. These data will not be used for any purpose other than for the research described above and the information you provide will not be made available to any individual or organization other than CASA’s researchers and statisticians. Information about you (e.g. your name, address, email ) will not be collected. No link will exist between your identity and the responses to the survey.

When will confidentiality be broken?
Confidentiality will not be broken under any circumstances. Because your name does not appear on the survey, and because we collect no other identifying information, there is no way to tie your responses to your identity.

What are my rights as a participant?
Taking part in this survey is voluntary. There is no penalty or consequence to you if you choose not to take part in this survey. You are free to skip any question(s) or to stop participation completely at any time during the survey completion process, with no penalty.