VIOLENCE PREVENTION FORMATIVE RESEARCH - CONSENT FORM

Please read this form carefully. This form will give you important information about the Research to Design Violence Prevention Intervention Messages project.

INVITATION TO TAKE PART

You are invited to take part in this research because you are an American Indian or Alaska Native male 18-24 years old, or are a topical expert in alcohol, violence, and health communication.

The Principal Investigator, or PI, is Stephanie Craig Rushing of the Northwest Portland Area Indian Health Board (NPAIHB), Tribal Epidemiology Center, Portland, OR. The PI is in charge of the research project. The research project will take place over 12 months.

PURPOSE OF THE PROJECT

We are working on a project to reduce alcohol-related violence among AI/AN young men 18-24 years-old. Right now, we are designing health messages and videos that will be delivered via text message using the NPAIHB’s multimedia health resource: www.weRnative.org 

To make sure the messages are relevant and useful, we are requesting feedback on our materials from community members and topical experts.

PARTICIPATION

If you decide to participate, you will be sent one campaign-related text message per day, followed by 3 or 4 questions asking what you thought of it (over 2-3 weeks in November), and a 10-minute survey at the end of the message sequence to share additional feedback.

Risks or Discomforts
There are very few risks from joining this study.  Some of the questions asked may be sensitive or embarrassing.  You do not have to answer any questions that make you feel uncomfortable.

CONFIDENTIALITY 
  • Your text message answers will not include your name.
  • Your name and address will be collected so we can mail you your incentive. This information will be used for mailing only and will not be kept after we have mailed you your incentive.
  • Any personal answers from you will be kept private as required by law. However, if you tell us about child abuse, elder abuse, suicidal thoughts, or wanting to hurt others, the research staff are required by law to report such information to the proper authorities.
  • Information from this study will be stored securely at our research offices. Only research staff will have access to any information you provide. All information will be destroyed after we completed this project.
  • Please note: As research staff, we could be required to report serious illegal behavior or criminal activity to the police or other authorities.  We encourage you not to tell us anything that would incriminate yourself or someone else of such behavior. 
COSTS OF JOINING THE PROJECT

You will receive $300 for reviewing and providing feedback on the text message series.  The feedback may take up to 15 minutes per day, plus a 10-minute survey at the end of the message sequence.

BENEFITS

This project may not help you directly. However, your answers will help the research team. This project hopes to create better health information for Native young adults.
JOINING AND LEAVING THE STUDY
  • Your participation is voluntary.  You may choose not to participate, you may stop the text messages at any time (by replying with “LEAVE”), or you may skip any questions that you do not want to answer. 
  • If you choose not to participate in this study, there will be no loss of benefits to you.
  • By responding to our text message questions, you agree to participate in this study.   It is your choice whether or not you decide to join this research.
  • You may choose to join now, but can change your mind and leave later if you want. In any choice you make, you will be treated the same way as usual.
IN CASE OF INJURY

You may become distressed by some of the health messages, videos, or survey questions asked as part of this project.  If you become too distressed, we will provide you with information on resources to help you.  If you are harmed as a result of being in this project, we cannot pay you.

RESEARCH CONTACTS

Questions about the purpose of the research can be directed to me, at 503-416-3290 or scraig@npaihb.org. 

This study has been reviewed by the Portland Area Indian Health Services’ Institutional Review Board [PAIRB #: 753252], which is responsible for protecting the rights and welfare of research participants and NW tribal members. 
 
If you have concerns or questions about your rights as a participant in this study, you may contact the Portland Area IHS IRB Chair, Dr. Weiser, at 877-664-0604 (toll free).

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* 1. Do you agree to participate in the "Rethink Your Drink" research study?

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* 2. You've replied AGREE to participate in this research study. Please confirm and enter your cell phone number:

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