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  • Reasons For Not Wanting To Participate RN P 112001

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    ark1974
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    This document is a form for recording a participant's reasons for not wanting to participate in a treatment program called Project COMBINE. The form includes checkboxes to indicate if various logistical, treatment-related, influence-related, or other reasons are given by the participant. For up to three most important reasons, the staff records the codes for those reasons. The form also collects information like the participant's ID number, initials, date, and staff member conducting the interview.

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    Reasons for Not Wanting to Participate Rn p 112001

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    This document is a form for recording a participant's reasons for not wanting to participate in a treatment program called Project COMBINE. The form includes checkboxes to indicate if various logistical, treatment-related, influence-related, or other reasons are given by the participant. For up to three most important reasons, the staff records the codes for those reasons. The form also collects information like the participant's ID number, initials, date, and staff member conducting the interview.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    7 views2 pages

    Reasons For Not Wanting To Participate RN P 112001

    Uploaded by

    ark1974
    This document is a form for recording a participant's reasons for not wanting to participate in a treatment program called Project COMBINE. The form includes checkboxes to indicate if various logistical, treatment-related, influence-related, or other reasons are given by the participant. For up to three most important reasons, the staff records the codes for those reasons. The form also collects information like the participant's ID number, initials, date, and staff member conducting the interview.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 2

    Date Entered___________ Staff Initials___________

    COMBINE Reasons for NOT Wanting to Participate (RNP ver A.)


    Center Participant # Participant Initials Week Sequence

    0 1
    Date Staff ID

    /
    mo. da.

    /
    yr.

    What are your reasons for not wanting to participate? (Check off all reasons given. Probe once: Anything else?) If more than 3 reasons are given, ask client to indicate the 3 most important reasons, out of all possible reasons on the form.. Code (98) Dont know; (99) N/A 0a) Reason #1 0b) Reason #2 0c) Reason #3

    Logistical/practical reasons Yes No (1) Too much time required (2) Objects to blood tests (3) Objects to urine tests (4) Inconvenient location (5) Childcare problems (6) Cant take time off from work (7) Plans to move out of area Treatment program related reasons Yes No (8) Does not want random or chance assignment (9) Does not want experimental treatment (10) Too intrusive / invasion of privacy (11) Thinks none of the treatments could help (12) Program too long / intense for needs (13) Program too short / superficial for needs (14) Prefers another treatment not offered in Project COMBINE (15) Objects to having to return for follow-ups for a year (16a) Dislikes one or more of the COMBINE treatments (16b) Record which treatment __________ Code: 1= CBI Alone 2= MM + Naltrexone 3= MM + Acamprosate 4= MM + Naltrexone + Acamprosate 5= CBI + Naltrexone 6= CBI + Acamprosate 7= CBI + Naltrexone + Acamprosate (17) (18) (19)
    RNP_6 (10/11/00)

    Prefers group format Doesnt want to take medications Wants medication but concerned about getting placebo
    Page 1 of 2

    Center

    Participant #

    Participant Initials

    Week

    Sequence

    0 1
    Date Staff ID

    /
    mo. da.

    /
    yr.

    Influence of others Yes No (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) Other (31a) (31b)

    Spouse/significant other Other family members Friends/co-workers Employer Therapist/counselor Health provider Clergy Court / probation / other legal pressure Other patients Hospital / clinic staff Members of support group or AA Other reason Specify: _________________________________________________________

    RNP_6 (10/11/00)

    Page 2 of 2

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