Consent form

This is a health survey that is being implemented by the Southern Plains Tribal Health Board (SPTHB) the Oklahoma Area Tribal Epidemiology Center (OKTEC). This survey is partially funded by a grant from the Indian Health Service, grant #U1B1IHS0009-15-02. Survey participants are recruited for the survey on a volunteer basis only and are estimating 500-1000 participants.

 

Important to us is the protection of your rights both as an individual and a tribal member. Your confidentiality will be protected by tribal, local, state and federal laws. Your name will not be associated with the survey. Only the SPTHB will have access to a locked cabinet containing any identifying information, which will not be released. This consent form will be kept separate from your survey answers and will not be identifiable or connected with the survey.

 

You and your answers are important to us. Your answers will be used to develop a tribal health profile for American Indians residing in the Kansas, Oklahoma, and Texas area. Your responses will provide insight to the health needs in our American Indian communities for setting health priorities and health improvement planning. You are not required to answer every question and may skip any questions you are uncomfortable with. You may also discontinue the survey at any time without an explanation.

 

Cuyler Snider with the Oklahoma Area Tribal Epidemiology Center can answer any questions you may have. Cuyler can be reached at (405) 652-9205 or by email at CSnider@spthb.org if you have questions about the survey. This survey was reviewed by the _Oklahoma City Area Indian Health Service_ Institutional Review Board (IRB). If you have any concerns in how the survey is conducted, you may contact _CAPT Ryan Schupbach at the _Oklahoma City Area Indian Health Service_ IRB to report these concerns by phone at _(405)951-3928_ or by email Ryan.Schupbach@ihs.gov.

Question Title

* 1. My checking "agree" below shows that I give my consent to participate in the survey and I understand the questions are necessary to help with determining needs of American Indians within the Kansas, Oklahoma, and Texas area. I understand that I am free to refuse to participate in this research project or to withdraw your consent and discontinue participation in the project at any time without penalty or loss of benefits to which I am otherwise entitled. Your participation will not affect your relationship with the involved SPTHB or any other institutions involved in this project. All information will be kept confidential and destroyed after completion of analyzation.

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