Consent Form

Consent Form

OMB Control Number: XXXX-XXXX

Expiration Date: XXXXX XX, 20XX

Mathematica Policy Research is conducting research on behalf of the Substance Abuse and Mental Health Services Administration (SAMHSA) to increase the quality of facility surveys. This study is intended to help the Office of the National Coordinator for Health Information Technology (ONC) and SAMHSA understand how electronic health records system have been implemented and used in behavioral health facilities.

Project staff from MPR, SAMHSA, and ONC will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347), the Public Health Service Act (42 USC 290aa(p)), and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. The Privacy Act notice below describes the conditions under which information related to this study will be used by Mathematica, SAMHA, and ONC.

We estimate it will take you an average of 30 minutes to participate in this research project.

Your participation in this research project is voluntary, and you have the right to stop at any time. If you agree to participate, please sign below.

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. OMB control number is XXXX-XXXX and expires XXXXX XX, 20XX.

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I have read and understand the statements above. I consent to participate in this study.

Participant's signature Date

Participant's printed name

Researcher's signature

PRIVACY ACT STATEMENT

Your voluntary participation is important to the success of this study and will enable MPR, SAMHSA, and ONC to better understand the behavioral and psychological processes of individuals when responding to these questions, as they reflect on the accuracy of SAMHSA’s information collections. Mathematica Policy Research, SAMHSA, and ONC, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347), the Public Health Service Act (42 USC 290aa(p)), and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent.