Community Survey

This section describes the purpose of the survey and asks for your consent to participate. Please review before taking the survey. This is the only question you are required to answer--you will be able to complete the survey once you have indicated your consent.

Question Title

* 1. Informed Consent for Participation

You are invited to take part in a survey that will help us to better understand the current status of Trinity County’s oral health, what are the needs of our community, and how should the County effectively address these needs.

The California Center for Rural Policy (CCRP) is doing a needs assessment for Trinity County Department of Public Health (TDPH). You have been asked to take part because you live in Trinity County. The information you give us about your oral health concerns and conditions will help us to work with Trinity Department of Public Health to develop a community health improvement plan for the County.

Overall Description of Participation 

If you decide to be a part of this project, you will be asked to "sign" this consent form which will allow you to move through the survey on-line. The survey is anonymous—your name is not anywhere on the consent form, and your consent is indicated by selecting the "yes" response below. The information you provide in your survey will be part of a dataset that will be used by CCRP and shared with TDPH. This needs assessment will be used to develop a Community Health Improvement Plan.  The plan will address many of the gaps in community services found in the needs assessment.  Your name will not be linked to the information on the survey.

Length of Participation 

The survey should take about 15-25 minutes to complete.


No compensation will be provided for participation in the survey.

Volunteer Statement 

You are a volunteer. Participating in this project is up to you. If you decide to be in the project, you may stop at any time and take back your consent to participate.  You will not be treated any differently if you do not participate in the project or if you stop once you have started.

Confidentiality Statement

Your name will not be linked to any information you give us as part of this study.  If results are shared with other people at meetings or in published articles, your name will be kept private.

Rights of Participants

If you have any concerns with this study or questions about your rights as a participant, contact the Institutional Review Board for the Protection of Human Subjects at or (707) 826-5165.

For specific questions about this study, you may contact the program coordinator, Dawn Arledge Director of Health Research at the California Center for Rural Policy (707-826-3400), or the program principal investigator, Connie Stewart, California Center for Rural Policy, HSU (707-826-3402).

Statement of Informed Consent

I have read and understood what it means to be a part of this project.  I understand that the investigator or program coordinator will answer any questions I may have concerning the investigation or the procedures at any time.  I also understand that my participation is entirely voluntary and that I may decline to enter this study or may withdraw from it at any time without jeopardy.  I understand that the investigator may terminate my participation in the study at any time.  

By clicking the "agree" statement below, I indicate that would like to be a part of this project and consent to take the survey.

Investigator:  Connie Stewart, Executive Director of the California Center for Rural Policy at Humboldt State University.

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