Contents

This page contains the following topics:

• Consent/Assent Form Information
• Data Use Agreement Information
• Score Calculation Sheets

Consent/Assent Form

Every Participant is asked to complete a consent/assent form which will allow or not allow their de-identified (no nickname, email address, ID) screener data to be used by researchers for secondary analysis.

Review a sample Consent/Assent Form here

Data Use Agreements (for Professional Accounts only)

The Data Use Agreement (DUA):

• Is a legal form that must be signed by an authorized individual at your agency/organization when your agency wishes their employees to use Screen4Success with individuals they serve.
• Explains that data will be hosted on servers under the control of Chestnut Health Systems, Inc. (the national coordinating center for Screen4Success).
• Explains that Chestnut Health Systems, Inc. must comply with the requirements of 42 C.F.R. Part 2, the HITECH Act, and the Privacy and Security Rules.
• Offers agencies/organizations the ability to contribute to an aggregated, de-identified Limited Dataset that will be analyzed by researchers to understand health, wellness and well-being, and assess health disparities, at the population level to inform policy and funding opportunities.

Important: You can send the DUA to be reviewed by the appropriate persons at your agency.

Review a sample DUA here:

Score Calculation Sheet

This spreadsheet shows and explains all the scores we calculate.