Uplift Research Use and Disclosure Consent Form

Research Use and Disclosure Consent Form

St. Vincent de Paul – 420 W Watkins Rd, Phoenix, AZ 85003 – is requesting your permission to collect and share information you provide to us with other agencies or partners to better assist you and others in need of assistance. This may include sharing with partners who help us evaluate our effectiveness in providing assistance to you and using your information in planning and delivering services. The agencies and partners we collaborate with may change over time, so the entities we share information with may also change accordingly.

There are numerous benefits to sharing your information:

· It may enable us to offer you more service options and expedite your access to services

· It may help prevent the need for you to repeatedly provide the same information to different service providers.

However, there are also some risks associated with sharing. It may involve the disclosure of sensitive information, and while all partners take precautions to mitigate these risks, there is always a possibility that data may be lost or stolen.

The type of information that may be shared includes but is not limited to identifying information (such as date of birth, social security number), demographic information (such as race, gender, ethnicity), and service history (such as housing, benefit programs). This also includes sharing your Personal Identifying Information (PII) for research, which includes linking to other administrative data sources or looking up additional information in other administrative data sources.

Your consent to sharing information is not a requirement to receive assistance from us. However, sharing your information can enhance our ability to assist you and others in need. You have the right to revoke this consent at any time by providing a written statement to us, including via email. If we have already shared your information with others to assist you, it may be more challenging for us or them to do so if you withdraw your consent.

We will provide you with a link to our privacy statement, which outlines how we protect and may share your information. If you are unable to access our privacy statement via the link provided, we will furnish you with a copy upon request.

Should you have any questions or concerns, please do not hesitate to contact us.

By signing below, you acknowledge your understanding and consent.

Signature: _____________________________

Name (Printed):

_____________________________________ Date: _________________________

Research Use and Disclosure Policy

1. Purpose

The purpose of this Research Use and Disclosure Policy is to outline guidelines for the collection, use, and disclosure of information gathered by St Vincent de Paul – Phoenix. This policy aims to ensure the ethical and responsible handling of data while promoting transparency and compliance with relevant regulations.

2. Scope

This policy applies to all employees, volunteers, contractors, partners and guests/patients of St Vincent de Paul- Phoenix.

3. Definitions

· Research: Systematic investigation designed to develop or contribute to generalizable knowledge.

· Data: Any information collected, stored, or processed for research purposes.

· Use: The utilization of data collected by St Vincent de Paul-Phoenix.

· Disclosure: The sharing or dissemination of data with external entities.

· Participant Consent: Permission obtained from individuals to use their data for research purposes.

4. Data Collection

· St Vincent de Paul- Phoenix collects data for research purposes with the consent of participants. Consent procedures are conducted in accordance with ethical standards.

· Data collection methods prioritize the protection of participant privacy and confidentiality.

· Data collected must be relevant to the research objectives and limited to what is necessary for the intended analysis.

5. Use of Research Data

· Research data collected by St Vincent de Paul-Phoenix may be used for various purposes, including program evaluation, needs assessment, and outcome measurement.

· Data use is restricted to authorized personnel involved in services, program administration/oversight/reporting and research activities.

6. Disclosure of Research Data

· Research data may be disclosed to external entities for collaborative research projects, evaluation purposes, or to fulfill legal or regulatory obligations.

· Prior to disclosing research data, St Vincent de Paul- Phoenix ensures that appropriate data sharing agreements are in place to protect participant privacy and confidentiality.

· Disclosure of data to third parties is done in accordance with participant consent.

7. Data Security and Confidentiality

· St Vincent de Paul-Phoenix implements measures to safeguard the security and confidentiality of data, including access controls, and secure storage systems.

· Access to data is restricted to authorized personnel with a legitimate need for access to perform their duties.

8. Compliance and Oversight

· Compliance with this policy is mandatory for all individuals involved in data activities at St Vincent de Paul-Phoenix.

· The Data Governance Committee (DGC) oversees the implementation of this policy and ensures adherence to ethical standards and regulatory requirements.

· Any concerns or violations of this policy should be reported to the DGC for investigation and resolution.

9. Policy Review

· This policy shall be reviewed periodically to ensure its effectiveness and relevance to St Vincent de Paul’s data activities.

· Amendments to this policy may be made as necessary to reflect changes in laws, regulations, or organizational procedures.

Research Participant Consent Form St. Vincent de Paul – Phoenix

I, [ ], hereby consent to participate in research activities conducted by St. Vincent de Paul – Phoenix. I have read and understood the Research Use and Disclosure Policy outlined by St. Vincent de Paul – Phoenix, and I voluntarily agree to the following:

1. Purpose of Research: I understand that the purpose of this research is to contribute to generalizable knowledge and support the mission of St. Vincent de Paul – Phoenix in providing assistance to individuals and communities in need.

2. Scope of Participation: I acknowledge that my participation in this research is voluntary and that I have the right to withdraw from the study at any time without penalty.

3. Data Collection: I consent to the collection of information about me for research purposes. I understand that data collection methods prioritize the protection of my privacy and confidentiality.

4. Use of Research Data: I understand that the data collected may be used for various purposes, including program evaluation, needs assessment, and outcome measurement by authorized personnel at St. Vincent de Paul – Phoenix.

5. Disclosure of Research Data: I acknowledge that my data may be disclosed to external entities for collaborative research projects or to fulfill legal or regulatory obligations. I understand that appropriate data sharing agreements will be in place to protect my privacy and confidentiality.

6. Data Security and Confidentiality: I understand that St. Vincent de Paul – Phoenix implements measures to safeguard the security and confidentiality of my data. Access to my data is restricted to authorized personnel with a legitimate need for access.

I have had the opportunity to ask questions about this research and understand that I may contact Laurie Sobel at St. Vincent de Paul – Phoenix for further information or clarification.

I hereby acknowledge my consent to participate in research activities conducted by St. Vincent de Paul – Phoenix.

Participant Signature: ________________________

Date: ________________________

Witness Signature (if applicable): ________________________

Date: ________________________

Please keep a copy of this consent form for your records.