Your Voice is Our Future Project_2022/ Proyecto Tu Voz es Nuestro Futuro_2022 |
Your Voice is Our Future Project_2022/ Proyecto Tu Voz es Nuestro Futuro 2022
Key Informant Interview Consent Form
Purpose of Survey:
The purpose of the Your Voice is our Future project is to gain insights into the unmet needs of the Bleeding Disorders Community of Southern California, that are serviced by the Hemophilia Foundation of Southern California (HFSC). The HFSC is working on identifying strategic priorities around unmet needs that will best serve the future of the Bleeding Disorders Community within the nine counties that HFSC services. It is important that we gather as much information so that HFSC can best serve your needs.
The purpose of the Your Voice is our Future project is to gain insights into the unmet needs of the Bleeding Disorders Community of Southern California, that are serviced by the Hemophilia Foundation of Southern California (HFSC). The HFSC is working on identifying strategic priorities around unmet needs that will best serve the future of the Bleeding Disorders Community within the nine counties that HFSC services. It is important that we gather as much information so that HFSC can best serve your needs.
You have been invited to participate in a survey with the Hemophilia Foundation of Southern California (HFSC). You will be asked to answer questions about (1) your needs, your family’s needs and/or your community’s needs and (2) the services available in your community to meet those needs. The purpose of this survey is to allow you to share your perspectives and experiences about your community. The information shared will be used to ensure that the right mix of services and activities are available throughout the service area.
Procedure:
The survey will last approximately 25 minutes. The survey session will consist of an electronic or printed survey.
Voluntary Participation:
Participation in this is voluntary. You are not obligated to participate. If you do participate, you may choose not to answer any questions with which you are not comfortable. You can end the survey at any time and for any reason.
Confidentiality:
This survey is confidential. Only staff at HFSC, or those individuals contracted by HFSC to do work related to the needs assessment, will be able to access information about your participation in this group. A report of this study may be published and may be presented at professional conferences, however only de-identified or group results will be stated. No personally identifying information about you will be published or presented.
Benefits and Risks:
The benefit of participation is the opportunity to inform HFSC of your community’s strengths and needs. There are no direct benefits or known risks to participation in this project.
Questions:
If you have any questions about the survey and the needs assessment process, you may contact either Sandra Valdovinos-Heredia at: svaldovi1982@gmail.com or Laura Wittcoff at: lwittcoff@gmail.com
I understand this information and agree to participate under the conditions stated above.
Print Name: _________________________________________
Sign Name: _________________________________________
Date: _________________________________________
Thank you in advance for taking the time and effort in completing this survey.
____________________________________________________________________________________________________
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Formulario de Consentimiento para la Encuesta
Propósito de la Encuesta:
El propósito del proyecto Su voz es nuestro Futuro es obtener información sobre las necesidades insatisfechas de la Comunidad de Trastornos Sanguineos del Sur de California, que son atendidas por la Fundación de Hemofilia del Sur de California (HFSC, por sus siglas en Ingles). La HFSC está trabajando en la identificación de las prioridades estratégicas en torno a las necesidades insa