Consent Form
Community Health Worker Employer Survey
Background Information: The purpose of this study is to examine the role of Community Health Workers in Illinois.
Procedures: Upon your agreement to participate in this study, you will complete a brief survey that will take approximately 10 minutes to complete.
Risks and Benefits Associated with the Study: This study does not have any known risks. The benefits in this study include contributing to the demand for timely, accurate information about Community Health Workers as valued contributors to the improvement of health outcomes and reduced health care costs.
Confidentiality: Your responses will be kept strictly confidential and digital data will be stored in secure computer files. Should the study ever become published material, your name will in no way be linked to the study, nor will it mention your personal involvement without your expressed consent.
Voluntary Nature of the Study: Your decision whether or not to participate is completely voluntary. You are free to withdraw at any time.
Contacts and Questions: The researchers conducting this study are Tom Hughes, Executive Director, Illinois Public Health Association and Georgeen Polyak, PhD, Benedictine University, Lisle, IL. If you have any questions or concerns regarding this study, please ask the researcher(s) at this time. If questions or concerns arise at a later time, you may direct them to gpolyak@ben.edu or thughes@ipha.com or to to Alandra Devall, Ph.D. Chair, Institutional Review Board, Benedictine University, 5700 College Road, Lisle, Il 60532, 630-829-6295 or adevall@ben.edu.
Statement of Consent:
Clicking the “NEXT” button below indicates that you are 18 years of age or older, and indicates your consent to participate in this survey.