COVID Project Consent Form  
UCSF, SFSU, Roots Community Health Center and Streetwyze are partnering on a new research project funded by the California Breast Cancer Research Program.

This project is about understanding how the COVID-19 pandemic and shelter-in-place policies affect individuals and their communities within Alameda, Contra Costa and SF counties, as well as understanding what local resources are important and useful at this time.

This project requires your consent to take part. Please take your time to make your decision about participating and discuss your decision with your family or friends if you wish. If you have any questions, the study team members below are available to explain and answer questions.

Project Directors:

Mindy Hebert-DeRouen, PhD, MPH, Research Scientist
UCSF Box 0560, 550 16th Street, San Francisco, CA.
Phone: 415.935-4787

Antwi Akom, PhD, Professor
1330 Broadway, Suite 300, Oakland, CA 94612
Phone: 510-473-5711

Study Coordinators:

Aekta Shah, Phone: 510-473-5711, E-mail:
Tessa Cruz, Phone: 510-473-5711, E-mail:

Sign in to Google to save your progress. Learn more
Email Address *
Phone Number
Do you live in Contra Costa, Alameda, or San Francisco County? *
Are you above 18 years old? *
Do you speak English? *
Do you have access to a smartphone or computer with WiFi/data *
Why is this study being done?
1. To understand how the COVID-19 pandemic and shelter-in- place policies are affecting individuals and their communities

2. To understand what local resources are important and useful at this time.

How many people will take part in this study?
There will be up to 100 individuals participating in this study.
What will happen if I take part in this research study?
If you choose to take part in this research study, there are two different options for participation:

1. Using a mobile, mapping website called Streetwyze to provide 10 stories/reports of neighborhood resources and neighborhood needs on the Streetwyze platform. These reports can be written words, voice recording, or video recordings about places on your neighborhood map

2. Taking between 1-4 surveys that asks questions about your current circumstances, including questions related to your work situation, financial needs, and access to food and housing during the pandemic.
How long will I be in the study?
The amount of time you spend in total on this study varies from person to person, but we anticipate that you will spend between 45 minutes to 1 hours, learning about the study, using Streetwyze if you choose to participate in that way. Each survey you respond to would take 10-15 minutes of your time.

After this study is complete, we will only contact you if you are okay with being contacted in the future for other studies.
Can I stop being in the study?
Yes. You can decide to stop at any time. Just tell the study researcher or staff person right away if you wish to stop being in the study.

Also, the study researcher may stop you from taking part in this study at any time if they believe it is in your best interest, if you do not follow the study rules, or if the study is stopped.
What side effects or risks can I expect from being in the study?
There are no risks to participating. We will take steps to maintain your privacy like storing your information securely. Any references to your identity that are present in your neighborhood reports will be removed from research data.

You do not need to provide any information that makes you feel uncomfortable. You can choose to not answer any questions at any time.
Are there benefits to taking part in the study?
If you take part by using Streetwyze, Streetwyze users often benefit from learning or developing ways to access neighborhood resources.

Researchers will use the information you provide with neighborhood reports or surveys in order to develop programs and policies to increase neighborhood resources during the pandemic. In this way, the information that you provide may help researchers to improve neighborhood resources. However, this research study does not guarantee that you will benefit directly from study results.
What other choices do I have if I do not take part in this study?
You are free to choose not to participate in the study. If you decide not to take part in this study, there will be no penalty to you.
Will information about me be kept private?
We will do our best to make sure that the personal information gathered for this study is kept private. Your name, phone number, birth date, email address, and device details will be kept securely by Streetwyze. This information will be stored separately from any research data, including neighborhood reports or survey responses you provide for the study.

Your address or cross-street of residence will be part of the research study so that we can understand how different neighborhoods have been affected differently by the pandemic. We will also ask you for your email address so that we can reach out when new surveys are available.

However, we cannot guarantee total privacy. Your personal information may be given out if required by law. If information from this study is published or presented at scientific meetings, your name and other personal information will never be used.

At the completion of the study, files containing your address, your email address will be deleted. You can still participate in this study if you do not want to provide this information. However, we cannot guarantee total privacy. Your personal information may be given out if required by law. If information from this study is published or presented at scientific meetings, your name and other personal information will never be used.
Will it cost me anything to participate in this study?
No. It will not cost you any money to participate in this project.
Will I be paid for taking part in this study?
You will be compensated up to $50 for participating in this study. You will be compensated $25 after providing 10 neighborhood reports. In addition, you will be compensated $10 for every survey that you complete.
What are my rights if I take part in this study?
Taking part in this study is your choice. You may choose to take part or not to not. If you decide to take part in this study, you may still leave the study at any time. No matter what decision you make, there will be no penalty to you in any way. It will not affect any of your regular benefits or the services you receive.
Who can answer my questions about the study?
You can talk to the researchers about any questions, concerns, or complaints you have about this study. Mindy DeRouen at, 415-935-4787 or Tessa Cruz at, 510-473-5711
PARTICIPATION IN RESEARCH IS VOLUNTARY. You have the right to decline to be in this study, or to withdraw from it at any point without penalty or loss of benefits to which you are otherwise entitled.
If you wish to participate in this study, please indicate your choice below *
 When you are contacted, you will be asked to provide consent for that specific study if you are eligible.
If you wish to be contacted about opportunities in future studies, please indicate your choice below. You have the right to decline and not sign this section of the form. *
If you wish to ask questions about your rights as a research participant to someone other than the researchers or voice any concerns please call the UCSF Institutional Review Board at 415-476-1814.
Any other questions?
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy