There is $15.00 being offered as compensation for the time required for you to
participate in this study. The benefits to improving your health care regarding physical health risks is a non-monetary potential benefit. This study does not pay for or provide compensation for any procedures or tests done during the office visit and no tests are required to participate. Ask the study staff if you have any questions about bills, fees or other costs related to this study.
What happens if I am injured or hurt during the study?
If you have a medical emergency during the study you should contact the researcher listed on page one of this form. You may also contact your own doctor, or seek treatment outside of the Avera Behavioral Clinic. In the event of any physical injury resulting from research procedures, medical treatment will be charged to your insurance and financial compensation is not available.
When is the study over? Can I leave the study before it ends?
This study will end when all participants have completed the interview and data collection is complete. This study may be stopped by your physician, if any health or safety hazard is identified or you are unable to complete the survey tools. You will be asked if you are willing to be contacted to participate in a future research with the study
tools planned by the researcher. If you are willing to be invited to participate in the future you will need to sign another consent form.
Confidentiality of Study Records and Medical Records.
Information collected for this study is confidential. However, de-identified data will be reported in a written research report of the principal investigator’s dissertation work toward Ph.D. completion. When data and analysis are presented, you will not be linked to the data by name, title or any other identifying item. Data will be kept in a password- protected electronic storage file. In the event of any publication regarding this study, your identity will not be disclosed.
Who can see or use my information?
Signing this form gives the researchers your permission to obtain, use, and share
information about you for this study, and signing is required to participate. Information about you may be obtained from Midwestern Wellness Institute, Marshall, Minnesota and the clinic care providers. Information obtained may include information about your health and your medical care before, during, and after the study, even if that information wasn't collected as part of this research study. For example: Midwestern Wellness mental health records and test results.
Reasons information about you may be used or seen by the researchers during this study can be to verify you can participate, to maintain information in a confidential database, to check for test results, or to ensure the study is done properly. The Institutional Review Board for South Dakota State University may need to ensure the study is safe.
What happens to information about me after the study is over or if I cancel my permission? When does my permission expire?
As a rule, the researchers will not continue to use or disclose information about you, but will keep it secure until it is destroyed. Sometimes, it may be necessary for information about you to continue to be used or disclosed, even after you have canceled your
permission or the study is over. This information would be used in a way that others would not be able to identify you specifically. Your permission will not expire unless you cancel it. You may cancel your permission at any time by writing to the researcher at address on the first page of this consent.
Who can I call about my rights as a research subject?
If you have questions regarding your participation in this research study or if you have any questions about your rights as a research subject don’t hesitate to speak with the principal investigator, Dawn Van Ruler at the number listed.
If you have questions regarding your rights as a research subject, you may contact the South Dakota State University Review Board (IRB) at 1 605-688-5642. You may call this number to discuss or report any problems, complaints, or concerns you have about the study. You may also call this number if you wish to talk with someone who is independent of the study.
When you sign this form, you are agreeing to take part in this research study. This means that you have read the consent form, your questions have been answered, and you have decided to volunteer. If you have additional questions about taking part in this study or research-related injury, you may contact – Researchers Contact Information was
Included Here”.
You understand taking part in this research study is voluntary. You may quit the study at any time without harming future medical care or losing any benefits to which you might otherwise be entitled.
I have read and understand the above information. I agree to take part in this study. I will be given a copy of this document for my own record.
________________________ ________________________ ___________
Name of Subject (Please Print) Signature of Subject Date
________________________ _______________________ ___________
Name of Person Obtaining Signature Date
Appendix N
Permissions to use The Serious Mental Illness Improvement Profile (HIP) tool Jacquie White <[email protected]>
Mon 6/16/2014, 11:51 AM Dear Dawn,
Yes I am the correct person regarding the HIP. I can easily send you a copy of the HIP but considering I have just completed a cluster RCT of it you may find it more helpful to have a chat about it.
It is free to use/adapt. We have a book coming out in a couple of months and hopefully a paper regarding the main results in the British Journal of Psychiatry.
In the meantime you can access a list of my publications that include all those so far published about the HIP at
http://www2.hull.ac.uk/fhsc/aboutus/staffcontactlist/jacquiewhite.aspx
With best wishes, Jacquie
Jacquie White
Deputy Head of the Department of Psychological Health and Wellbeing 209 Dearne Building, Faculty of Health and Social Care,
University of Hull, Hull, HU6 7RX
Skype: Jacquiew23
01482 464537 (Direct Line), 01482 463342 Faculty Helpdesk http://www.hull.ac.uk/fhsc