Sample volunteer consent for domestic violence study
The NoName Family Crisis Center asks you to take part in a research study about violence in the homes in NoName community.
The study will help us understand the type and severity of violence that occurs in NoName homes. The Crisis Center will use the study to plan better programs to prevent domestic violence, and to treat the family victims of violence including children.
We are asking to interview all women seen by the Center. Please understand that you will always get care by the Family Crisis Center whether or not you agree to take part!
If you agree to take part, your counselor will put some of your story into the research. Neither you nor anyone will be named or identified.
You told the counselor your history already. If you agree, she will use the facts of your history for the study. She may ask a few more questions, to complete your history. An IHS doctor will also review your chart for injuries you had that may be related to problems with your partner.
She also will want to talk with you one month and six months after the first visit.
She will ask you how you are doing. You can tell her then what you thought about the Crisis Center, and what should be done to help you and other women, families, and children.
She knows that your partner may be angry if he found out you talked with us. So, she will ask you what is the best way to contact you to set up a time to talk. She will contact you only by the way you want. The Family Crisis Center is a safe place to come and talk.
Source: Indian Health Services of the Department of Health and Human Services, Washington, DC. Web site: www.ihs.gov.
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