Consent Form

We invite you to participate in a Community Health Needs Assessment survey. The purpose of this survey is to understand the needs in our community. The results will aid Saint Joseph Health System (SJHS) in developing action plans to address health-related problems. The goal is to hear from residents about health challenges in St. Joseph, Marshall, and Elkhart counties, and how to solve them.

There are no known risks if you decide to participate in the survey, nor are there any costs for participating. The information you provide will help SJHS understand how best to satisfy the needs of the community. The information will be available for government and private agencies interested in the needs of the community. We will not share your individual information.

We ask for your ZIP code in order to learn different needs associated with different parts of the tri-county region. Information you provide will remain confidential and surveys will be available only to the researchers conducting the survey.  

Your participation in this study is voluntary. If at any time you wish to discontinue participation, you may do so with no penalty to you. Nothing you say on the survey will be used against you. The interviewer may choose to terminate participation if deemed necessary at any time.  

If you have any questions or concerns about completing the survey or about being in this study, you may contact Michelle Peters at petermic@sjrmc.com or 574-335-4685.  

YOU ARE MAKING A DECISION WHETHER OR NOT TO PARTICIPATE IN THIS SURVEY.  YOUR SIGNATURE INDICATES THAT YOU HAVE READ THE INFORMATION PROVIDED ABOVE, ARE AT LEAST 18 YEARS OF AGE, AND HAVE DECIDED TO VOLUNTARILY PARTICIPATE IN THE SURVEY. 

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* INDICATE CONSENT

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