Consent to Participate in Research

INTEGRATION OF SUBSTANCE USE DISORDER TREATMENT WITH PRIMARY CARE IN PREPARATION FOR HEALTH CARE REFORM

Survey
You are being asked to take part in a research study by ____, Ph.D., from the Integrated ___. You were selected as a possible participant in this study because you are the lead contact for your organization in the Health Resources and Services Administration’s Uniform Data System, a designee of the contact person, or were identified as an appropriate participant by stakeholders in your area. Your participation is voluntary, and you may withdraw at any time.

PURPOSE OF THE STUDY
The purpose of this study is to better understand the current level of integration of substance use disorder (SUD) treatment with primary care and the barriers and facilitators to such integration. Please note that EVEN IF YOUR ORGANIZATION DOES NOT CURRENTLY PROVIDE SUBSTANCE USE DISORDER SERVICES, YOUR PARTICIPATION IS VERY IMPORTANT.

PAYMENT FOR PARTICIPATION
You will be provided with a $100 gift card for participation. If you start but do not complete the survey, or if you skip any questions, you will still receive the $100 gift card.

PROCEDURES
You are being asked to participate in a web-based survey lasting from 8 up to 22 minutes (depending on responses) to collect data on types of SUD treatment, use of evidence based SUD treatment practices, integration between SUD and primary care, mental health, and HIV/AIDS services, organizational characteristics, and the degree to which policies (e.g. Medi-Cal reimbursement rules) affect delivery of services.

POTENTIAL RISKS AND DISCOMFORTS
You may not wish to answer some questions. You may refuse to answer any question that you do not wish to answer, or stop the survey at any time.

POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
This study will not provide any direct benefits to participants. However, this study will give you an opportunity to voice your opinions and share your experiences regarding SUD service integration, and your input will be an important source of information that will be disseminated to policymakers interested in this topic. This may potentially lead to improvements in policies and practices that affect your organization and others like it.

CONFIDENTIALITY
All of your responses will be encrypted and accessible only to the researchers. All of the information you provide will be identified by a code number and will be used for research purposes only. All data collected will be kept in locked files at the researchers’ office. No information that identifies you will be shared with other research programs, or with other agencies, or be released without your separate consent. All data reported in publications or reports will be in aggregate form, meaning that no individual will be identified. When the results of this study are published, your name will not be used.

PARTICIPATION AND WITHDRAWAL
Your participation in this survey is voluntary. If you do decide to participate, you are free to withdraw your consent and stop the survey at any time. You may also refuse to answer specific questions you do not want to answer and still remain part of the study.

IDENTIFICATION OF INVESTIGATORS
If you have any questions or concerns about the research study, please feel free to contact ___, Ph.D., the Principal Investigator at ___. He can also be called at ___ or by writing to___.

RIGHTS OF RESEARCH SUBJECTS
You are not waiving any legal claims, rights or remedies because of your participation in this study. If you wish to ask questions about your rights as a research participant or if you wish to voice any problems or concerns you may have about the study to someone other than the researchers, please call the Office of the Human Research Protection Program at (310) 825-7122 or write to Office of the Human Research Protection Program, UCLA, 11000 Kinross Avenue, Suite 211, Box 951694, Los Angeles, CA 90095-1694

SIGNATURE OF STUDY PARTICIPANT
I have read (or someone has read to me) the information provided above. I have been given an opportunity to ask questions by contacting the researchers and all of my questions (if any) have been answered to my satisfaction.

Question Title

* 1. Click on the button below if you agree.

 
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