Risks and Discomforts:
The risks are minimal. They involve possible breaches of
confidentiality or privacy when discussing sensitive issues with Interviewers,
or emotional discomfort when recalling or talking about substance abuse.
To protect the confidentiality of the research data, we will code all provided
information using a unique ID number for each participant, and the participant’s
name and other identifying information will be contained in a single master
file, accessible only to senior research staff and kept in a locked file
cabinet in the Principle Investigator's office. You should be aware
that the Department of Health and Human Services can request access to
these data. All records will be destroyed 5 years after the completion
of the grant. To assist in the event that psychological trauma may
arise when talking about substance abuse, the Principal Investigator and
his key staff will contact you and make consultation arrangements.
A list of local emergency rooms, community hospitals, and mental health
clinics serving your region will facilitate the referral process.
Potential Benefits:
By assisting, you contribute information, which will be used
to help develop future programs to help others who live in Illinois also
trying to live clean and sober lives. In addition, you receive payments
for your time in answering the questions.
Investigator’s responsibilities:
The project has been fully explained to
(participant) including the nature and purpose of the above-described research
procedures and the risks and benefits involved in its performance. Questions
have been answered and all future questions will be answered to the best
of my ability. I will inform the participant of any changes in the procedures
or the risks and benefits if any should occur during or after the course
of the study. A copy of the consent form has been provided to the
participant.
Date Investigator’s Signature
Participant’s Consent:
The above procedure described has been satisfactorily explained
with its possible risks and benefits and my questions have been answered.
Permission for my participation in this study has been granted. Dr. Leonard
Jason or his associates may be reached at (773) 325-2018 and will be available
to answer any questions that may arise. Questions regarding my rights as
a research subject or questions regarding compensation in the event of
a research related injury may be asked of a member of the DePaul University
Institutional Review Board by calling (773) 325-2593. Freedom to withdraw
this consent and discontinue participation in this project at any time,
even after signing this form, is assured. A copy of this form has
been provided to me.
To participate in this research project, please sign and print
your name below. Your signature indicates that the information provided
above has been read, or was read, and that you have decided to participate.
Date Signature of Participant
Date Witness to Signatures
TELEPHONE INFORMATION
Please list the DAY, TIME and PHONE NUMBER that may be best for completing
the "DePaul University Phone Interview". Please remember there are
a number of questions to answer, so list times that set aside 60 minutes
to answer all items.
WEEK DAY TIME OF DAY AREA CODE
-PHONE NUMBER
________ _______ ( ) ________________
________ _______ ( ) ________________
________ _______ ( ) ________________
________ _______ ( ) ________________
THANK YOU FOR YOUR PARTICIPATION.
Release Form – Important Person
It is understood that the most important person in my social network
will be contacted by telephone by a person from DePaul University representing
a study on what happens after people finish treatment for drug and alcohol
problems.
Permission is granted to have this important person contacted: _______________________
(Print Person’s complete
name)
This important person can be reached at the following telephone number
.
This important person’s address is
.
DATE: __________________ SIGNATURE: _______________________
(please PRINT your name here -______________________________ )
DATE: WITNESS:
Release Form –Contact Person who can Locate Me
It is understood that a person from DePaul University, representing a study on what happens after people finish treatment for drug and alcohol problems, will need to contact a person who is always aware of where and how to reach me.
Permission is granted to have this person contacted to provide the investigators at DePaul information on where and how to reach me:
___________________________ (Print Person’s complete name)
This person can be reached at the following telephone number
.
This person’s address is
.
DATE: __________________ SIGNATURE: _______________________
(please PRINT your name here -______________________________ )
DATE:
WITNESS:
CONSENT FORM (To be sent to the Most Important Person in Network)
Description and Explanation of Procedure:
A group of investigators at DePaul University (Chicago, IL) are
conducting research of persons who have left treatment facilities for alcohol
and drug abuse.
(Participant’s Name) has listed you as the most important person who knows (him or her). This person has given us permission to contact you and ask about (his or her) current level of alcohol and drug use. We are now requesting your permission to be interviewed. If you agree to be interviewed by us, we will call you within the next week. You can refuse to answer any questions that we ask you.
Risks and Discomforts:
The risks are minimal. They involve possible breaches of
confidentiality or privacy when discussing sensitive issues with an Interviewer.
To protect the confidentiality of the research data, we will code all provided
information using a unique ID number for each participant, and the participant’s
name and other identifying information will be contained in a single master
file, accessible only to senior research staff and kept in a locked file
cabinet in the Principle investigator's office. Of course, the participant
will be aware that you are supplying information about him/her to us and
he/she has agreed to allow us to contact you for this purpose. You should
be aware that the Department of Health and Human Services can request access
to these data. All records will be destroyed 5 years after the completion
of the grant.
Potential Benefits:
By assisting, you contribute information, which will be used
to help develop future programs to help others who live in Illinois also
trying to live clean and sober lives. No direct benefits to you may
be expected.
Investigator’s responsibilities:
All information will be confidential, used solely for research
purposes, and held the researchers at DePaul University. Of
course,
(participant’s name) will know if you have provided information about his/her
alcohol and drug use.
(participant) has read or been read the nature and purpose of the above-described
research procedures and the risks and benefits involved in its performance
has been fully explained. Questions have been answered and all future questions
will be answered to the best of my ability. The participant will be informed
of any changes in the procedures or the risks and benefits if any should
occur during or after the course of the study. A copy of the consent form
has been provided to the participant.
Date Investigator’s Signature
Participant’s Consent:
The procedure described above has been satisfactorily explained
to me, including its possible risks and benefits and my questions have
been answered. Permission for my participation in this study is granted.
Dr. Leonard Jason or his associates may be reached at (773) 325-2018
and will be available to answer any questions that may arise. Questions
regarding rights as a research subject or questions regarding compensation
in the event of a research related injury may be asked to a member of the
DePaul University Institutional Review Board by calling (773) 325-2593.
Freedom to withdraw this consent and discontinue participation in this
project at any time, even after signing this form, is assured. A copy of
this form has been provided to me.
To participate in this research project, please sign and print
your name below. Your signature indicates that you have read the
information provided above, or have had it read to you, and that you have
decided to participate. Please return this form in the stamped envelope
that is enclosed.
Date Signature of Participant
Date Witness to Signatures
TELEPHONE INFORMATION FOR THE COLLATERAL
Please list the DAY, TIME and PHONE NUMBER that may be best for completing Phone Interview. Please remember, there are a number of questions to answer, so list times that set aside 10 minutes to answer all items.
WEEK DAY TIME OF DAY AREA CODE -PHONE NUMBER
________ _______ ( ) ________________
________ _______ ( ) ________________
________ _______ ( ) ________________
________ _______ ( ) ________________
THANK YOU FOR YOUR PARTICIPATION.