The purpose of the screen is to see if you are eligible to participate in the full study in which you can complete a survey about alcohol use behaviors and experiences of discrimination and/or microaggressions for gift card compensation. You may also be selected to take part in testing a mobile assessment tool for 7-days and to complete an interview via Zoom with the research team to provide feedback on this tool.

The National Institute on Minority Health and Health Disparities is funding this research study.

In order to determine if you are eligible for this research study, we would like to ask you a few questions. This is called an online screen. The online screen is for research purposes and could last about 1-2 minutes. In this screen, you will be asked some questions about your age, race, and alcohol use, and access to a smartphone. If you prefer to do this at another time, please reach out to the research team at (314) 362-9003 or email ichasmsurvey@wustl.edu.

If you choose to complete your screen, after your screen is completed the research team may reach out via email or phone to verify your information and eligibility for the study. You will only be asked to provide this information one time during the study, and you should only share information that you are comfortable sharing.

A risk of participating in this online screen is that confidential information about you may be accidentally disclosed. You will not benefit from participating in the online screen. We will keep the information you provide confidential by protecting saving this information on a password protected server and restricting access to only those on the research team. If you are not eligible to participate, we will destroy any link between your name and your study ID number. Any report or article we write will not include information that can directly identify you. However, federal regulatory agencies and Washington University, including the Washington University Institutional Review Board (a committee that reviews and approves research studies) and the Human Research Protection Office may inspect and copy records pertaining to this research activity.

To further protect your privacy, this research is covered by a Certificate of Confidentiality from the federal government. This means that the researchers can refuse to disclose information that may identify you in any legal or court proceeding or to anyone who is not connected with the research except if:

• there is a law that requires disclosure, such as to report child abuse and neglect, or harm to self or others;
• you give permission to disclose your information, including as described in this consent form; or
• it is used for other scientific research allowed by federal law.

This Certificate may not be effective for information held in foreign countries.

You have the right to share your information or involvement in this study with anyone at any time. You may also give the research team permission to disclose your information to a third party or any other person not connected with the research.

Your participation in this online screen is completely voluntary. You may choose not to take part at all. If you decide to participate in the online screen you may stop participating at any time. Any data that was collected as part of this online screen will remain as part of the study records and cannot be removed. If you decide not to take part in the online screen, or if you stop participating at any time, you won’t be penalized or lose any benefits for which you otherwise qualify.

If, after completing this online screen, you are eligible for the research study, you will be asked at a later date to sign a separate consent form that includes more detailed information about the study.

Before I ask you the screening questions, I would like to tell you about what we will be doing with the information you give us.

Your answers to the screening questions will create Protected Health Information (PHI) that identifies you. Your health information is protected by law under HIPAA (the Health Insurance Portability and Accountability Act). Because of this law, you will need to give the research team permission to use and share your protected health information from the online screen for this research.

When possible, the research team will make sure information cannot be linked to you. Once information doesn’t identify you, it may be used and shared for other purposes not discussed during this online screen.

The information collected today during the online screen may be seen by people making sure the research is being done right. This may be people at Washington University or the National Institutes of Health.

• If you agree, you are giving permission for us to use of your PHI for this research, and your permission will not expire.
• If you do not agree to allow us to use your PHI it will not affect your treatment or the care given by your health provider, insurance payments or enrollment in any health plans, or any benefits to which you are entitled. However, it will not be possible for you to take part in the online screen for this study.
• Once your health information is shared with someone outside of the research team, it may no longer be protected by HIPAA.
• If you change your mind and do not want the research team use or share your information, you will need to provide a written letter to the research team cancelling your permission. Please contact the Human Research Protection Office for more information on how to revoke your authorization or contact the research team to request the withdrawal letter. If you do this, the research team may only use and share information already collected for the study. You will not be allowed to continue to participate in the study.
• If you have questions or concerns about your privacy and the use of your protected health information, please contact the University’s Privacy Officer at 866-747-4975.

We encourage you to ask questions. If you have any questions about the research study itself, please contact the research team at (314) 362-9003 or ichasmsurvey@wustl.edu. If you have questions, concerns, or complaints about your rights as a research participant, please contact the Human Research Protection Office at 1-(800)-438-0445 or email hrpo@wustl.edu. General information about being a research participant can be found on the Human Research Protection Office web site, hrpo.wustl.edu. To offer input about your experiences as a research participant or to speak to someone other than the research staff, call the Human Research Protection Office at the number above.