RETAIN-CT Baseline Survey Enrollment Form Retaining Employment and Talent after Injury/Illness Network Connecticut (RETAIN-CT) Consent Information I have read the consent form and agree to share my contact information with UConn Health for research purposes only (you will be sent a copy of the consent form by email).RETAIN-CT RESEARCH STUDY (BASELINE SURVEY) Purpose of this Research: The purpose of this research study is to determine if special training and resources provided to health care providers in your area has improved health and work outcomes for workers who experience musculoskeletal pain or injury. The RETAIN-CT project is a federally funded quality improvement effort being conducted in the Hartford, CT region. The project involves specialized training to health care providers, additional insurance reimbursement for their assistance with patients for return-to-work planning, and to provide greater access to return-to-work coordinators and other services. Some health care providers are participating in the RETAIN-CT quality improvement project, while others are not. Because of this quality improvement effort, you may receive more return-to-work assistance from your healthcare provider, and you may be offered the optional assistance of a return-to-work coordinator. Voluntary Participation: You are being asked to participate in a research study because you are a worker with recent musculoskeletal pain or injury, and your employer is insured by an insurance company of The Hartford Financial Services Group, Inc. (“The Hartford”). Participation is voluntary. Participation will involve approximately one hour of your time over the next 12 months. You will be asked to complete one 20-minute questionnaire today, then another in 3 months, and then a final survey in 12 months. The questionnaires will include questions about your job, your workplace, your pain and function, your overall health, and your satisfaction with the healthcare you have received. There are no physical risks associated with completing the survey, however you may feel uncomfortable answering some of the questions. You may always choose not to answer any questions that make you feel uncomfortable. Risks to Confidentiality: Electronic research files will be kept on password-protected and encrypted computers. Any computer hosting such files will also have password protection to prevent access by un-authorized users. Participants will be assigned a unique subject ID. A master key that links names and codes will be maintained in a separate and secure location away from the study data. Data that will be shared with others will be coded as described above to help protect your identity. You should also know that: • At the conclusion of this study, the researchers may publish their findings. Information will be presented in summary format, and you will not be identified in any publications or presentations. • If you discuss this study with your employer or co-workers, your study participation may become known to others. Payment for Participating: To compensate you for your time, you will receive an online Amazon gift card for $25 or $50 after you complete the initial survey, depending on how many sections you choose to complete. You will also receive an online Amazon gift card for $50 after completing a survey in 3 months, and another $50 gift card after completing a survey in 12 months. The gift cards will be e-mailed to you within 7-10 days after completing each survey. At the end of this survey, you will be asked to provide us with the email address where you would like your Amazon gift card to be sent. Withdrawing from Participation: You are free to withdraw from the study at any time. However, your earlier information will be retained and could have been already shared with external parties as described above. If you decide not to participate or you withdraw from the study, your decision will not affect your present or future medical care you receive at UConn Health/John Dempsey Hospital or your workers’ compensation claim with The Hartford and there will be no penalty or loss of benefits to which you are otherwise entitled. If you decide to withdraw, we ask that you let us know by calling Dr. William Shaw, PhD, at 860-679-8946 or by sending a written notice to Dr. William Shaw, PhD, at UConn Health 263 Farmington Avenue Farmington, CT 06030-2945. Data sharing: If you choose to sign this consent and complete the RETAIN-CT surveys, information you provide, including survey responses, SSN, date of birth, and other information, will be combined with information provided by The Hartford. The Hartford will send to UConn Health certain identifiable personal information regarding your claim, including diagnosis information. The combined information collected for this research study will be sent by UConn Health to authorized persons. Authorized persons include study team members and representatives of UConn Health. Authorized persons also include the Connecticut Department of Labor, the Social Security Administration, a federal evaluation contractor Mathematica Policy Research (“Mathematica”), Office of Management & Budget (“OMB”), the U.S. Department of Labor (“DOL”), and ADNET Technologies (an Information Technology contractor) (the “Government Entities”). Further, there is a possibility throughout the course of the study that other records held by The Hartford, which could include personal information such as medical records or discussion notes, would be viewable by or need to be provided to the Government Entities by The Hartford. Information provided to Government Entities could be subject to disclosure to other external parties if requested and released under Freedom of Information Act laws (“FOIA”). UConn Health and The Hartford are receiving money from the U.S. Department of Labor to do this study. The DOL requires that we share information we gain from this study with authorized persons listed above, which will be used for present and future statistical data and individual-level analysis. Further, researchers at Mathematica will use this information to study whether the RETAIN quality improvement efforts with health care providers in your region have improved work outcomes using SSA program and earning records. There is a small risk of an accidental release of personal information. SSA, Mathematica, and the Connecticut Department of Labor have extensive procedures in place to prevent this from happening. They would inform you immediately of any specific threat to your privacy. If you do not consent to such sharing, do not complete the survey. Role of insurer: Your survey responses will not be shared with your claims handler or anyone else at The Hartford. The Hartford is not managing RETAIN-CT, has no control over present and future data use by UConn Health or governmental entities that will receive data, and makes no representations regarding the program, including but not limited to data security or privacy. Consent to Participate: By signing below, you acknowledge that you have read and understand this information sheet and that you consent to participate. An extra copy of this form has been sent to you for your records. If you have any questions regarding your participation in the study, please do not hesitate to contact the Principal Investigator of this research study, Dr. William S. Shaw, at 860-679-8946. Full Name First Middle Last Mailing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Phone NumberThank you for providing your contact information. The research team will be in contact with you shortly with information about how to complete the initial survey. In the meantime, if you have any questions, they can be directed to the Dr. William Shaw, the Research Lead for the RETAIN-CT project, at 860-679-8946 or firstname.lastname@example.org.