WELCOME TO THE SCREENING SURVEY!
When taking this research survey, if at any time you lose your Internet connection or need to stop, please use the same link to complete the survey.
You are free not to answer any question that you do not wish to answer, and can refuse to participate or withdraw from participation at any time without penalty.
THANK YOU FOR YOUR INTEREST!
Online Screening Consent Statement/Information Statement
Welcome to Project PATH!This research is being conducted by Dr. Melissa Lewis from the School of Public Health at the University of North Texas Health Science Center located in Fort Worth, TX. This study has been approved by the North Texas Regional Institutional Review Board. If you would like to ask any questions about this information or about our confidential study, please call us at 817-735-2371 or e-mail PATH@unthsc.edu.
We would like to invite you to participate in a confidential research study. The purpose of our study is to explore health and risk behaviors, including alcohol and drug use, in adolescents and young adults. We are interested in recruiting people between the ages of 15 and 25, including both individuals who do not drink alcohol and who do drink alcohol. The information you provide for this study may help our research team to better understand who engages in certain types of health or risk behaviors and why.
Online screening survey and phone verification process:
Baseline/12-month survey and daily surveys:
Unless you withdraw from the research study, the researchers can continue to use or share your de-identified (no identifiers) information indefinitely. The researchers will be publishing articles and presenting data at conferences. Data will be de-identified (no identifiers) by the end of the study.
Participating in this study is voluntary. You may refuse to answer any question and still submit your survey without penalty or loss of benefits to which you are otherwise entitled. You are free to withdraw at any time without penalty or loss of benefits to which you are otherwise entitled.
Researchers will only retain your contact information if you are eligible for this study or if you are age 18 or older and agree (during the screening survey) to be contacted for future research studies. If you are ineligible for this study and you do not agree to be contacted for future research studies, your contact information will be deleted within 30 days and not be used in any way. If you are eligible for this study or if you are age 18 or older and agree to be contacted for future research studies, your contact information will only be used for the purposes of contacting you about the study or future research studies and we will retain your contact information indefinitely unless you request to no longer be contacted for future studies.
If you are 15-17 years old, you and your parent/guardian’s contact information will be deleted within 30 days in the event that your parent/guardian does not grant consent, or does not respond to the consent invitation or repeated consent reminders.
If you choose to “like” our Facebook Fan Page and/or “follow” our Instagram or Twitter, you may see more posts from us about our latest projects/activities, general updates, and other fun things.
The risks associated with participation in this short online survey are primarily related to the sensitivity of some of the questions. If you are age 18 or older, you will be asked about personal behaviors such as alcohol use, drug use, and sexual behavior. These questions may make you feel uncomfortable or may seem intrusive, or you may become concerned about your drinking or other health behaviors as you answer the questions. You are asked to report on illegal behaviors, such as drinking under the legal age, or using controlled substances. Answers to these questions could pose a risk if the information were known and linked to identifiable individuals. It is possible that you will feel uncomfortable while taking the survey, or feel as if you should share information that you don’t want to share. Additionally, there is informational risk since your contact information will be maintained for at least 30 days. However, we have taken steps to protect you from this risk. All of your data will be kept confidential and data will be identified only by a PIN (personalized identification number) randomly generated for research purposes, and will not be identified by participants’ names. The PIN is always embedded in survey links, meaning the link is specific to you and your survey data. Thus, you will not ever need to enter your PIN to complete study surveys.
If you would like to participate, please indicate your consent/assent below.
Melissa A. Lewis, Ph.D., Principal Investigator
Please answer the question below and hit NEXT (regardless of your answer).
This study has been explained to me. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the researchers listed above. If I have questions about my rights as a research subject, I can call the North Texas Regional Institutional Review Board at (817) 735-0409.
Your research records will be kept as confidential as possible under current local, state, and federal law. However, federal regulatory agencies and the North Texas Regional Institutional Review Board may examine your records.
Please click the box indicating whether or not you would like to participate.
(Note: by checking YES you are only consenting to this initial screening phase of the project and not the entire research study. You will also be asked to provide a drawn e-signature and asked to type your full name.)
Please sign and complete the information below if you checked the “YES” box above. This information will document your consent for this initial screening survey. All of your responses will be kept confidential.
Electronic Signature: (click or tap to sign)
Typed Full Name:
Please enter your email to receive a copy of this signed consent form for your records.
Email (e.g. PATH@unthsc.edu)
Please submit your completed consent form by pressing the ‘Next’ button below.
You indicated that you DO NOT want to participate in Project PATH at this time.
If this is INCORRECT, and you DO want to participate, please press [Back] and change your response.
If this is CORRECT, please confirm:
A Longitudinal, Measurement Burst Study to Examine the Ecological Validity of the Prototype Willingness Model of Hazardous Adolescent and Young Adults Alcohol Use (Project PATH)
Principal Investigator Name:
Melissa A. Lewis
The purpose of this form is to give your permission to the research team at the University of North Texas Health Science Center (“UNTHSC”) to obtain, use or share your protected health information (PHI). This protected health information will be used to do the research named above. UNTHSC understands that information about you and your health is personal and we are committed to protecting the privacy of that information in accordance with state and federal privacy laws. Because of this commitment, we must obtain your written authorization before we may collect, use or share your protected health information for the research study listed above. This form provides authorization and helps us make sure you are properly informed of how this information will be used or disclosed. You do not have to sign this permission form. If you do not sign, UNTHSC will not obtain, use or share your protected health information for research. Please note though that you will not be able to participate in the research study. Your decision to not sign this permission will not affect any treatment, health care, enrollment in health plans or eligibility for benefits.
"This document is also used for parents to provide permission to obtain the individual health information of their minor children, and for legally-authorized representatives of subjects (such as an appropriate family member) to provide permission to obtain individual health information of individuals who are not capable themselves of providing permission. In such cases, the terms “you” and “your health information” refer to the subject rather than the person providing permission.
A minor’s signature is required to release the following information about the minor: 1. Age 14 and older – information relating to reproductive care, including but not limited, to birth control and pregnancy-related services and sexually-transmitted diseases, including HIV/AIDS and 2. Age 13 and older – substance abuse diagnosis or treatment, and mental health information."
In this form, “protected health information” (PHI) refers to any health information that identifies you, such as:
If you sign this form, you give UNTHSC permission to obtain, use or share the following health information as part of this research study:
UNTHSC is required by law to protect your health information. By signing this form you authorize UNTHSC to obtain, use or share your health information for this research. Those persons who receive your health information may not be required by Federal privacy laws to protect it and may share your information with others without your permission, if permitted by laws governing them.
Health information about you created or generated during the course of this research study.
Your protected health information may be obtained, used, or shared with these individuals or organizations for the following purposes:
Any protected health information disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and is no longer protected.
If you agree to be in this study, the research team may use or share your protected health information in the following ways:
No, you are not required to sign this document. If you decide not to sign this document, you will still receive the same clinical care, or any services you were already entitled to receive. However, if you do not sign the document, you will not be able to participate in this research study.
This permission to release your Protected Health Information expires when the research ends and all required study monitoring is over.
You can cancel your permission at any time.
You can do this by writing to the researcher. Please send your written request to:
Project PATH Staff
Department of Health Behavior and Health Systems
School of Public Health
3500 Camp Bowie Blvd; EAD suite 708
Fort Worth, TX 76107-2699
You have the right to take back your permission at any time, except to the extent that the research team has already taken action in reliance on your permission. If you cancel your permission, you may no longer be in the research study.
If you cancel, no more health information about you will be collected. However, information that has already been collected and disclosed about you may continue to be used as necessary to maintain the integrity of the study (i.e., complete the research). Also, if the law requires it, the sponsor and government agencies may continue to look at your protected health information to review the quality or safety of the study.
Please call us at 817-735-2371 with any questions.
If you agree to the use and release of your Protected Health Information, please sign using your electronic signature below.
Consent for Specific Health Information and Use
The following information will only be released if you give your specific permission, which is required by Federal and state laws, by putting your initials on the line(s). The federal rules bar any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
I agree to the release of information pertaining to drug and alcohol abuse.
I agree to the release of information pertaining to mental health.
Required Signature for HIPAA Authorization:
Subject Typed Full Name:
Subject Electronic Signature: (click or tap to sign)
If this form is being read to the subject because s/he cannot read the form, a witness must be present and is required to type his/her name and sign here.
Witness Typed Full Name:
Witness Electronic Signature: (click or tap to sign)
If you provided your email, you will receive a copy of this statement for your records.
Please click below to proceed.