DATA ENTRY LINK Youth Access to Mental Health Services in Rural Pennsylvania
RESIDENT SURVEY CONSENT FORM
You are invited to participate in a research study being conducted through Kutztown University. We ask that you read this form and ask any questions you may have before you decide whether or not you want to participate in the study. The University requires that you give your agreement if you choose to participate. This study is being conducted by Dr. Juliana Svistova (Principal Investigator), Associate Professor of Social Work at Kutztown University of Pennsylvania.
Title of the Study: Access to Mental Health Services in Rural Pennsylvania
Purpose of the Study: The purpose of this research study is to assess the demand of mental health services in rural Pennsylvania with a focus on youth and the elderly and identify the challenges these populations face in accessing mental health care so as to identify options for improving and expanding mental health care services for the underserved rural Pennsylvanians.
Procedures: If you agree to participate in this study, we would ask you to fill out the survey that is provided in this link. It should take you approximately 15 minutes.
Risks or Discomforts, and Benefits of Being in the Study: There are no foreseeable risks to participating in this study. We expect that participants may find it rewarding to engage in and contribute to a research study that is designed to help improve mental health care system in Pennsylvania.
Confidentiality and Anonymity: Records will be kept private and will be handled in a confidential manner to the extent provided by law. In any report or presentation, we will not include any information that will make it possible to identify a research study participant. Your identity will remain anonymous in any presentations or reports.
Voluntary Participation: Your participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled, and you may discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled.
Contacts and Questions:
Dr. Juliana Svistova, Associate Professor, Department of Social Work
Kutztown University of Pennsylvania
Old Main 337, PO Box 730, Kutztown, PA 19530
If you have questions later regarding the research study, you may contact the researcher listed above. If you have any questions or concerns about the rights of research participants, please contact the IRB Committee at Kutztown University at 484-646-4167.
Compensation: All survey participants will be eligible for a chance to win a $25 store gift card. A total of 20 people will be randomly selected to receive the gift cards.
Statement of Consent: I have read/heard the information described above. I have asked questions I had regarding the research study and have received answers to my satisfaction. I am 18 years of age or older and voluntarily consent to participate in this study.