Preparing a Computerized Tool for Preventing Prenatal Drinking for a Larger Trial
Phase: NA
Conditions: Foetal Exposure During Pregnancy
Sponsor: Public Health Institute, California

Page 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Title:  Computerized Tool for Preventing Prenatal Drinking 
 
NCT Number: NCT02337361 
 
Date of Document:  May 1, 2015 
 
 
 
PROTOCOL INFORMATION 
 
Approved by the California Committee for Protection of Human Subjects, June 15, 2015 
 
 

Page 2 
 
PROTOCOL INFORMATION:    
 
 
 
 
 
 
 
 
  
 
  1.  Purpose of the study 
  a) Include a brief statement , less than 500 words, describing the research project. Be sure to 
address the background for the project, including relevant literature, the major research 
questions to be addressed, and the expected end product (e.g., article, report or other 
publications). Include the location(s) where the project will take place. The summary should be 
understandable to the general public. 
 
Prenatal alcohol use, a leading cause of preventable birth defects in the U.S., continues to be a public health 
problem (Ethen et al., 2009). Screening and brief intervention (SBI) reduces drinking but remains underutilized due to 
resource limitations in public health care. Delayed pregnancy recognition and stigmatization concerns related to 
disclosure of drinking (Jacobson et al., 2002) further hamper prevention efforts with pregnant women. Heavy drinking 
increases risk for unintended pregnancy and for prenatal drinking. Thus, high rates of heavy drinking and of unplanned 
pregnancies in women in the U.S. suggest the need for primary prevention with all women of childbearing age.  Barriers 
to SBI with pregnant women indicate that innovative programs are needed to prevent prenatal alcohol use.   
Our study seeks to adapt a self-administered, computerized screening and brief intervention (electronic SBI or “e-
SBI”) for drinking during pregnancy for use with non-pregnant women of childbearing age and to conduct a preliminary 
test of its efficacy.  We previously successfully piloted the e-SBI for drinking with pregnant WIC clients. We now seek to 
test the efficacy of e-SBI in reducing drinking among non-pregnant women at two Northern California WIC sites. 
Our e-SBI is innovative in several ways. It is self-administered and uses actual drinking vessels and photographs of 
drink containers to assess individuals’ drink sizes. It then uses that data to provide personalized feedback about how 
much the individual is actually consuming in standard drink equivalents. Finally, our e-SBI is in English and Spanish and 
will address gaps in care for Hispanic women, an increasing portion of those attending public health clinics. 
Our study design incorporates innovative methodological features, including studying if assessing drink size can 
reduce drinking by itself and if depression modifies e-SBI efficacy. This will provide preliminary information related to 
how and for whom the e-SBI works. We expect to disseminate our findings via publications in scientific journals and 
through networks of participating organizations as well as networks of the local county and state perinatal health 
professionals and substance abuse treatment professionals. Because it begins to build an evidence base for e-SBI 
efficacy for reducing prenatal alcohol use, our study is of significance for improved maternal and child health. Findings 
will also impact the larger literature on cost-effective strategies to reduce alcohol-related harm.  
Specific aims of the study are to: 
Aim 1. Adapt a computerized SBI (e-SBI) for drinking during pregnancy for use with women of childbearing age.   
Aim 2.  Conduct a small randomized trial of the e-SBI with an intervention group (e-SBI, n=100) and a control group 
(usual care, n=100) at two WIC program sites.   
Aim 3. Use drink size assessment to better measure drinking outcomes, and explore efficacy for the drink size 
assessment component of the e-SBI.    
Aim 4. Explore if depression modifies alcohol use outcomes for e-SBI. We expect that within the intervention and 
control group each, women reporting depression will reduce their drinking less than those without depression.   
  (484 words) 
 
CITATIONS 
Ethen MK, Ramadhani TA, Scheuerle AE, Canfield MA, Wyszynski DF, Druschel CM, Romitti PA (2009) Alcohol 
consumption by women before and during pregnancy. Matern. Child Health J. 13:274-285. 
Jacobson SW, Chiodo LM, Sokol RJ, Jacobson JL (2002) Validity of maternal report of prenatal alcohol, cocaine, and 
smoking in relation to neurobehavioral outcome. Pediatrics 109:815-825. 
 
 

Page 3 
 
b)  What is the major research question to be addressed in this project? 
The study examines efficacy of electronic screening and brief intervention for reducing alcohol consumption 
among women of childbearing age. 
2. Study Procedures: All project types) 
  a) Describe all study procedures. Please note: The box below is for text only. If you would like to add tables, charts, 
etc., attach those files in the Attachment section. 
Data collection will be conducted at two sites of the Women, Infants and Children (WIC) program that are 
interested in participating in the proposed study, the Sonoma County WIC site in Santa Rosa, and the La Clinica de 
la Raza Fruitvale WIC (see letters of interest and organizational support).  Data collection with human subjects 
involves the following:  1) Individual testing of e-SBI and assessment software by a total sample of 20 women at 
the clinic prior to software finalization to enhance its acceptability and usability for study participants; 2) 
recruitment of non-pregnant women attending the WIC clinic to participate in a short computerized screening, 
including that for alcohol use to identify study eligibility. Those reporting drinking 5 or more drinks in a day or 8 or 
more drinks in a week within the past year will be eligible for the trial.  3) computerized random assignment of c 
women eligible for the trial to one of two study conditions, i.e., to receive the e-SBI (experimental group) versus 
usual care (control group); 4) completion of a baseline assessment on alcohol use, any drug and tobacco use, 
sweetened beverage consumption, with the e-SBI for the experimental/intervention group only; 5) completion of 
3-month follow-up computerized assessments; and 6) completion of 6-month follow-up computerized 
assessments. 
 
Study procedures include several tasks as detailed next.  Also see Figures 1 and 2 attached that provide an 
overview of expected recruitment numbers and study procedures.   
Adaptation the e-SBI for use with non-pregnant women.  Our first study aim is to adapt a recently piloted 
computerized SBI for drinking during pregnancy for use with non-pregnant women of childbearing age. The 
adapted e-SBI, like that for drinking during pregnancy, piloted at the Richmond WIC site in 2012-2013, will be self-
administered via a computer with a touch-screen monitor.  Adaptations include text changes to content to 
increase relevance of messages for reduced drinking relevant for non-pregnant women who potentially could 
become pregnant and drink prior to pregnancy recognition. Expert review (consultant, clinic staff) and feedback 
from women testing our study program in the preparatory period will be used finalize content modifications. 
 
Development of the computerized study program. Most of the study procedures will be computerized. The 
computerized study program will include informed consent and all study assessments.  It will also deliver the e-SBI 
to participants who screen eligible and are randomized into the intervention condition, and provide all needed 
referral information. Thus, the computerized study program will include a) the informed consent b) all study 
assessments including at baseline, 3 months and 6 months; c) a screening module to identify risky drinkers for 
study inclusion (those who drink 8 or more drinks in a week or five or more drinks in a day); d) computerized 
randomization of eligible participants to the two study trial conditions (intervention or the brief alcohol 
intervention vs control or usual care); e) at baseline: a brief alcohol intervention for the intervention group only; 
f) at the 3-month follow up: a booster (re-administration of) e-SBI for the intervention group; and g) at 3- and 6-
month follow up: drink size assessment for both study groups.  See study program flowcharts in the attachments 
for an overview of the modules of the computerized study program. 
The Brief Alcohol intervention Like other SBIs, our e-SBI for drinking during pregnancy includes alcohol 
assessment and feedback, information on alcohol-related harms and benefits of reducing consumption, and a 
personalized plan for reducing consumption.  The plan includes goal setting, an analysis of high risk situations for 
drinking, and suggested coping strategies. Two components of our e-SBI set it apart from prior interventions: 1) A 
drink-size assessment that uses a display of actual drinking vessels (9 glasses) placed above the study computer 
(see the storyboards for the computerized study program for a picture of the vessels display); and photographs or 
other drink containers (glasses, bottles, cans) to assess beverage-specific drink sizes; 2) Drink size feedback that 
educates users about standard drink sizes and reviews discrepancies between their drink size and the standard 

Page 4 
 
size for each beverage, highlighting that she may be drinking more than she thinks she does. 
 
Preparatory Period: This will include testing of study procedures and computerized study program. Following beta 
testing and elimination of programming errors for the computerized study program, we will use a 2-month 
preparatory period to test and finalize our computerized study program and the recruitment and data collection 
procedures at both study sites.  This is critical to identify any unanticipated problems and to ensure the study 
procedures do not impact staff work load. 
We will recruit 10 non-pregnant women (5 English speaking and 5 Spanish speaking) at each of the two WIC 
sites to test the computerized study program.  In our prior work with e-SBI for drinking during pregnancy at a 
Contra Costa county WIC site, we found individual testing of the e-SBI feasible and relevant and used it 
successfully.     
Clinic staff will inform eligible participants about testing of the computerized study program, clarify that 
participation is voluntary and does not affect services received at the site in any way. Interested participants will 
approach the private study area where the research assistant will help them review and complete the informed 
consent.  Participants will be paid $20.00 each for testing the program.  No identifying information will be 
collected from these participants.  However, we will ask participants for their WIC ID number to ensure that they 
do not participate again in the study.  
 
Recruitment of participants for the study 
Posters and recruitment flyers leaflets that provide basic information about the study as a health study will 
be used for recruitment (see attachment).  Posters, with the same information as the flyers but in larger size, will 
be placed in visible areas identified in close consultation with staff at each site.  WIC staff will inform eligible 
women about the study by providing them a copy of the recruitment flyer with brief study information at the end 
of their visit and will indicate where the private study area is located.  WIC staff will clarify to clients that study 
participation is voluntary, they will not know who participated or not as no study data is shared with staff, and 
that study participation will not affect clients WIC services in any way. Interested women will then approach the 
Research Assistant (RA) on site. 
In order to ensure that WIC clients do not feel pressured to participate in the study, particularly because 
several clients return every 2 to 3 months for their food checks, after 2 months of recruitment, WIC staff will not 
provide each participant the recruitment flyer.  Instead, staff will ask eligible clients if they know about the study 
and only provide a copy of the recruitment flyer to a client who specifically asks for it. 
 
Screening, administration of the computerized intervention, and follow up assessments will be completed by the 
computerized study program administered through a PC using a touch screen monitor placed in a private area of 
the site. Each study computer will have a drinking vessel display with 9 different glasses for use during the drink 
size assessment (see computerized study program storyboards attached for a picture of the drinking vessel 
display).  We will use more than one computer and monitor to administer the study program if needed, providing 
privacy to each participant with the use of screens/room dividers as appropriate for the space at the specific site. 
The RA will ask an interested participant, who approaches her and expresses interest in the study, for her 
WIC ID number.  We propose recording the participant’s WIC ID for purposes of identity verification only, needed 
for incentive payments and check-in for the follow up assessments. Clients at the WIC program typically check in 
with their WIC ID. Thus, this ID represents a convenient and reliable form of identification for participants to 
provide.  The RA will explain to the participant that the WIC ID number is recorded for identification purposes to 
help avoid participants doing the program twice and that the ID information is not part of the study data.  The RA 
will start the computerized study program by entering a unique study ID matched to the participant’s WIC ID. 
Study consent will be administered electronically. In reviews for our prior e-SBI study with pregnant women, 
electronic consent (by selecting “I agree” on the pertinent screen) was deemed acceptable for research purposes 
by both the Public Health Institute and the Contra Costa County Regional Medical Center Institutional Review 
Boards.  A participant may decline or stop participation at any point during the study by pressing a stop sign 
present on each screen of the computerized study program.  If the participant presses “stop”, the computer will 
ask if it may store the data allowing the participant to select a response to eliminate the data. Because data on 

Page 5 
 
where women stop the program is useful for program improvements, we will delete that participants data at the 
end of the day after recording which program screen she touched the stop button on.  Women completing 
screening who report risky drinking will be eligible for the trial.  The computer will randomly assign these women 
to receive the alcohol intervention or not and then to complete the baseline assessment 
Women will use the computerized program independently, with the RA available on site to answer questions 
and address any unanticipated problems.  At completion of the program, an encrypted email will be generated to 
the RA which includes the following password-protected information, none of which is personal identifying 
information: Study-ID and whether screening only vs full baseline assessment was completed.    The program will 
also prompt participants to meet the RA to collect their payment and provide needed follow up information.  The 
RA will a) provide the incentive payment (gift card); and b) obtain contact information for purposes of follow-up. 
Participants will be paid $5.00 if screened only and $30.00 each for baseline and follow-up assessments if enrolled 
in the trial. Contact information obtained will include the participants’ name, phone number and other contact 
information needed to reach them to schedule their follow up appointments. All follow-up appointments will be 
schedule to coincide with subsequent visits to the WIC site. The RA will explain to participants that all identifying 
information collected will be confidential, secured and kept separate from the data. 
We expect over 80% of participants to use cellphone and text messaging services based on use reported in a 
2011 study at a southern California WIC program. Participants will also be provided with cellphone numbers to 
reach the RAs if needed.  RAs will use contact information to check-in with participants  once in the interim 
between interviews, specifically, 6 weeks after the baseline interview and 6 weeks after the 3 month interview  in 
order to ensure that the contact information is current or to update this information as needed, and to send 
reminders regarding the follow-up assessments via text messages and/or telephone.  In these phone calls and text 
messages, the following script will be used “This is [name of RA] from the Health e-Wise study for Women. Your 
next appointment is on [Date]. Please call [number for RA] if your phone number has changed, if you need to 
change your next appointment, or have any questions. Thank you.” Voicemails and text messages will only be 
used with prior verbal consent of the participant, obtained when the contact information is collected and only 
when the participant cannot be reached by phone. 
We will observe implementation periodically throughout the duration of the study to proactively address any 
problems. 
 
  b) State if audio or video taping will occur. Describe how the tapes will be maintained during and 
upon completion of the project. Describe what will become of the tapes after use (e.g., shown at 
scientific meetings, erased, etc.). 
Audio-recording of feedback regarding the computerized study program will be obtained only 
from women testing the program with their consent (see consent form).  The recordings will be 
erased once transcribed, within a week of the recording.  No other identifying information will 
be obtained from women testing the study program (preparatory period of study). 
c) State if deception will be used. If so, provide a rationale and describe debriefing procedures. 
Submit a debriefing script in the Attachment section. 
Our study does not involve deception.   
 
While the recruitment materials do not mention alcohol to reduce stigma for participants, the 
informed consent materials clearly indicate that the computerized study program asks about use of 
alcohol and includes our full organization name (Alcohol Research Group-Public Health Institute) in 
the title.   
 
The informed consent also contains information that participants who screen eligible for the larger 
study (the trial) may receive the computerized brief intervention or not (usual care).  See statement 
“ DrinkWise may  give you information on healthy drinking. “ 

Page 6 
 
   
3 Testing of a New Drug or Device (Common Rule projects only) 
If a new drug or device is being tested, 
 
 
 
 
are copies of the state and federal documents that   
 
 N/A 
permit the investigators to proceed attached? 
 
4. Study Affiliation: (All project types) 
a. Is the name of the database or specimens, such as blood  
 Yes 
 No 
spots, listed? 
 
 
 
 
 
 
 
 N/A 
 
b. Is California Health and Human Services Agency staff,  
 
 Yes 
 No 
funding or state mental hospital patients identified? 
 
 N/A 
 
4a. If data or specimens from departments within the State of California are being requested, list the 
department name and the formal name of the data base or specimen registry. 
Does not apply.  No data or specimen are being requested from the organizations interested in 
participating. 
 
4b. List any California Health and Human Services Agency department(s)’ involvement in providing 
research staff, funding and/or patients from State mental hospitals for this project. 
We seek to recruit participants at two WIC program sites in Northern California the Santa Rosa 
WIC and La Clinica De La Raza, Oakland’s Fruitvale WIC.  Non-pregnant clients at these sites who consent 
to participation will complete all study procedures at these sites during routine visits to the WIC 
program.   
 
No staff from these sites will be involved in the research.  Research staff for the project will be 
hired by the Principal Investigator’s organization, the Alcohol Research Group-Public Health Institute 
(ARG-PHI). 
   
Note: if neither of these categories are listed, the project may not be in CPHS’ purview. 
 
5. Subject Population: (All project types) 
Is the subject population adequately  
 
 
 
 
 Yes 
 No 
described? This includes data elements being used, recruitment and screening methods, age, gender, 
ethnicity, vulnerable populations, and rationale for studying these populations. 
 
5. Subject Population 
 
    In the space below, please describe the participants that you are requesting to recruit (include 
requested participant number and description of each group requested). For data-only studies, 
describe the databases or records to be accessed and the data elements to be obtained.  
a) Provide a full description of how human subjects will be involved in the research. Address 
characteristics of subjects, such as age, sex and ethnicity and number of participants. 
Consenting non-pregnant women who are 18 to 44 years of age who have not been pregnant in the past 6 months 
will be eligible for the study screening.  Participant self-reported information will be used to exclude pregnant women. 
Specifically, when a potential participant selects “yes” to the item “are you currently pregnant” on one of the first few 
screens of the computerized study program, the program will terminate and clarify that only women who are not 
pregnant are eligible for the study.   
Women reporting at-risk drinking, defined as heavy (5 or more drinks in a day) or frequent (8 or more drinks in a 
week), drinking will be eligible for the randomized trial.  These risky drinking criteria are used in prior brief intervention
studies with women of childbearing age due to increased associated risk for birth defects and growth deficiencies. We 

Page 7 
 
will not exclude women who report alcohol-related problems. Instead the computerized study program will provide 
referral information to these participants as per standard of care at the participating WIC sites.   
There is no known safe drinking level during pregnancy. Since all participants in the trial will have met risky drinking 
criteria at baseline, the computerized study program will also provide referral information and brief information on 
harms associated with drinking to participants who become ineligible at follow up because of being pregnant. Among 
these participants, those who were assigned to the intervention at baseline will additionally receive information 
reminding them of the intervention they received (see storyboards for the computerized study program, screens 18A 
and 18B). 
b) If existing data will be obtained, list the database(s) to be used, the time period(s) being 
requested. This may include requests for future data that is not available at this time. List or 
attach a list of variables ( in the Attachment Section, Attachments) being requested and justify 
the need for each variable and for the quantity of data being requested. Also, will participants be 
involved in any other studies? 
Does not apply as no existing data is being requested for the present study. 
c) What is the rationale for studying the requested group(s) of participants? 
Our study uses a follow-up design to examine the efficacy of e-SBI as a tool for low resource settings to improve 
access to care for diverse groups of childbearing age women. It  is best conducted at Women, Infants and Children 
(WIC) program sites for three reasons.   1) WIC serves a large portion of childbearing age women, mostly of low-
income and minority status.  2) WIC Clients return to the program site at least every 3 months for their food checks.  
This makes WIC the ideal location to recruit low income women of child-bearing age for a follow up study that can be 
completed at their convenience during a visit to the program.  3) Our prior work on e-SBI was also conducted at a WIC 
program site in Northern California. 
d) Describe how potential subjects will be identified for recruitment. Examples include: class rosters, 
group membership, individuals answering an advertisement, organization position titles (i.e., 
Presidents, web designers, etc.). How will potential participants learn about the research and how 
will they be recruited (e.g., flyer, email, web posting, telephone, etc.)? Attach recruitment materials 
in the Attachment Section, Attachments. Important to remember: subjects cannot be contacted 
before IRB approval. 
Recruitment of participants for the study 
Posters and recruitment flyers/leaflets that provide basic information about the study as a 
health study will be used for recruitment (see attachment).  Posters will be placed in visible areas 
identified in close consultation with staff at each site.  WIC staff will also inform eligible women 
about the study by providing them a copy of the study flyer at the end of their visit and will indicate 
where the private study area is located.  WIC staff will clarify to clients that study participation is 
voluntary, they will not know how participated or declined as no study data is shared with staff and 
that study participation will not affect clients WIC services in any way. Interested women will then 
approach the research assistant in the private study area.   
To minimize burden on WIC staff and to maintain the needed separation between the WIC 
program and the proposed study for clients as well as avoid staff influencing participation in any 
way, WIC staff will not answer any questions about the study or provide any other clarifications. 
Instead, if a potential participant has any queries, WIC staff will direct them to conger with the 
research assistant  

Page 8 
 
e. Screening Procedures: If subjects will be screened prior to entry into the research, please address 
the criteria for exclusion and inclusion in the research. Provide reasons for not including women or 
minorities. Provide justification for including vulnerable populations such as children or prisoners. 
Please also provide a statement regarding what will happen to the information collected about the 
individual, should they not enter into the study. 
Inclusion Criteria 
All consenting non pregnant women who are 18 to 44 years of age and have not been pregnant 
in the past 6 months will complete a screening using the computerized study program.  Given that 
our study focuses on examining the efficacy of a computerized brief intervention for drinking, 
women who report at-risk (5 or more drinks in a day) or frequent (8 or more drinks in a week) 
drinking will be eligible for inclusion in the trial.  These criteria are used in prior intervention studies 
with women of childbearing age due to increased associated risk for birth defects and growth 
deficiencies.  Because, WIC clients are predominantly of minority ethnic status, both women and 
minorities will be included in the study.  
Given recruitment of women of age 18 to 44, the study will include participants ages 18-20. 
Children below the age of 18 are expected to comprise a small portion (5% or less) of all non-
pregnant WIC clinic attendees and will not be included in the study. Women age 18 to 20 are legally 
considered adults and not minors and can independently consent to medical care and provide 
informed consent for the study.  
While brief interventions are typically not used with drinkers who need more intensive 
treatment than available in primary care settings, we will not exclude women who report alcohol-
related problems.  Instead, the computerized study program will provide referral information to 
participants who report alcohol-related problems as per standard of care at WIC. Usual care at WIC 
includes providing referral lists with names and phone numbers for diverse health care services, 
including for alcohol and substance use and depression.   
Exclusion Criteria. Pregnant women will not be included in the study as the intervention being 
studied is for non-pregnant women.  Hence if women enrolled in the trial become pregnant after 
the baseline assessment, we will exclude them from the follow-up assessments.   
 
Screening data and data for participants who do not complete the study. 
Data from participants who are screened only but not eligible for inclusion in the trial due to 
not drinking at risky levels are also of value to us as it provides us demographic and health 
information for the larger population of women attending WIC.   Should women discontinue the 
computerized program at any point in time and wish to not participate, their permission will be 
sought to retain the data collected to the point they exited.  If participants do not consent to their 
data being used, their data will be deleted.  
 
f) Explain the amount, nature, e.g.; gift card, cash, and schedule of compensation, if any, that will 
be paid for participation in the study. Include provisions for prorating payment. The amount 
should not be coercive. 
Participants will be paid with gift cards (e.g., My Choice gift cards from Safeway). Participants will be 
paid $5.00 if screened only and additionally, $30.00 each for baseline, three-month and six-month follow-up 
assessments.  Thus a participant who completes the study will be paid a total of $95.00 in gift cards.  Given that 
the screening takes only 5 minutes, it would not be meaningful to prorate the $5.00 payment for screening.   For 
those enrolled in the trial each assessment will take no more than 20-30 minutes, for which they are paid $30.00 
each. Our consent form is clear about payment being made for completing the needed assessment.  It states 
“For each part of the study you finish, you will be paid $30. So if you finish all 3 parts, you will make $90. This is 
in addition to the $5 you will be paid for completing the first set of questions.  

Page 9 
 
However, prorated payments will be provided to each trial participant who returns for the follow up 
assessment and find that she is no longer eligible for the study because she is now pregnant. These participants 
will spend no more than a minute on the computerized study program as the initial screen confirms pregnancy 
status.  We will pay these participants $5.00 instead of the $30.00 they would have received if they had 
remained eligible and completed the follow-up assessment. 
  
g) Estimate the probable duration of the entire study. This estimate should include the total time 
each subject is to be involved and the duration the data about the subject is to be collected (e.g., 
This is a 2-year study. Participants will be interviewed 3 times per year; each interview will last 
approximately 2 hours. Total approximate time commitment for participants is 12 hours.) 
We expect that we will need to screen consenting participants for roughly 10 months to identify 
120 women with risky drinking for the randomized trial at each of the two study sites. With an 
estimated refusal rate of 20%, we would then enroll 100 participants at each site in this 10-
month-period.  The last enrolled participant (in month10) will complete the 6 month 
assessment.  Thus we expect the duration of data collection to be 16 months.  Hence, allowing 
for a two-month-study-preparatory period, to test the computerized study program and study 
procedures, we expect the total duration of the study to be 18 months.  
Participants who screen eligible for the trial will complete 3 assessments, 3 months apart within a 
6 month period.  We expect each assessment to take a maximum of 25-30 minutes, with the total 
approximate time commitment for a participant being 1.5 hours.    
6. Risks: (All project types) 
Are the risks and risk level, minimal or greater than  
 
 Yes 
 No 
minimal risk, described and justified? 
Risks (Input N/A if not applicable) 
 
US Department of Health & Human Services (HHS) Regulations define a subject at risk as follows: "...any 
individual who may be exposed to the possibility of injury, including physical, psychological, or social injury, as a 
consequence of participation as a subject in any research, development, or related activity which departs from 
the application of those accepted methods necessary to meet his needs, or which increases the ordinary risks of 
daily life, including the recognized risks inherent in a chosen occupation or field of service." 
 
 
a) Provide description of risks, physical, psychological, social or economic, loss of data security and confidentiality 
to subjects. Describe and justify risk level (minimal, moderate or high). 
This study includes data collection on sensitive information on alcohol, tobacco and drug use, and mental health. 
Hence associated risks are: 1)Embarrassment or awkwardness with answering very personal questions and associated 
increased awareness of alcohol use problems and depression due to the study assessment; 2) possible stigmatization 
due to alcohol use or poor mental health;  and 3) potential risk of loss of confidentiality of personal, private information.  
Based on our prior work with women of childbearing age and that reported in the larger scientific literature, we 
estimate that the risk of the study questions causing distress to participants will be minimal. However, several 
procedures will be used to provide protection against risks related to discomfort and stigmatization related to answering 
sensitive questions. We will ensure that participants are treated with the utmost respect and their privacy is 
safeguarded. Prior to study initiation, all study personnel will complete human subjects training procedures and other 
requirements for ensuring confidentiality, including a responsible conduct of research online course and signing a 
confidentiality statement for the study.   
All study assessments will be conducted via computer in a private space within the WIC site.  Additional privacy 
features, such as a privacy screen/room divider will be used when more than one participant is in the study area.  We 
will make every attempt to space use of the computerized study program at least 10 minutes apart for participants to 
further maximize participant privacy.  
Several features of the computerized study program are aimed at increasing participant privacy and autonomy and 
reducing any embarrassment or awkwardness.  Obtaining consent electronically precludes the need for signatures and 

Page 10 
 
removes barriers to refusing participation that an in-person interaction may engender.  Additionally, participants can 
decline to participate or stop participating at any point during the study without penalty by pressing the “stop” button 
on the screen.  
Explicit consent will be obtained for including study data for participants who choose to not complete the study. 
If the “stop” button is used, the computer asks the participant for permission to store any data collected. If the 
participant declines, her data will be deleted from the study data. Additionally, the informed consent specifies that 
refusal to participate will remain confidential and will not affect services received at WIC or the larger health care 
system WIC is a part of in any way. 
Minimizing potential risks of loss of confidentiality of personal, private information is of utmost importance. 
Women receiving public health services may be particularly concerned about stigma related to substance use and 
mental health issues and may fear of losing health benefits if they disclose sensitive information.  Therefore, several 
measures will be taken to reduce possible stigmatization for participants.  Publicly available materials for the study (the 
study name, recruitment posters, flyers) will not mention alcohol or the risky drinking criteria for enrollment in the trial.  
All other study materials, computers and monitors used to administer the study program, drinking vessel display and 
referral information will be placed in a private area.  The drinking vessel display does not have any alcohol bottles and 
the glasses displayed are commonly used glasses, often used in households for juice and water.    
Finally, the referral information will be as per standard care at WIC.  Women who report alcohol-related problems 
or depression will be presented with a screen that lists relevant referral information for services.  The information on 
these screens will include a note that the referral information is part of standard WIC referral information materials and 
that the RA can help point out relevant services on the WIC referral materials if needed.  In this way, participants will not 
have any materials that distinguish them from other WIC clients as study participants or those needing services for 
alcohol or mental health, thereby further reducing stigma-related risks.    
Given that no study data will be shared with WIC, staff will have no way of know which participants completed 
screening only or were found eligible for the trial.  This reduces risk of stigma related to participants being identified as 
risky drinkers. We will attend WIC staff monthly meetings to reiterate the importance of clinic staff not influencing 
participation in the study in any way. In these meeting we will stress that staff communicate to clients that the study is 
voluntary, does not affect services received in any way, and that data is kept confidential by the research staff and not 
shared with clinic staff.  
To minimize risks related to loss of confidentiality of the information collected, which includes personal information  
for identification (WIC ID number) and for follow up purposes (name, phone number and other contact information) and 
study data,  safeguards will be used, including:  
1) Precluding identifying information, such as name, address, and other contact information in the computerized 
assessments and, thereby, study data.  2) keeping all study materials will be confidential and used for research 
purposes only.  Access to data will be restricted to research staff and data from the study computers which will be 
encrypted (password-protected) to prevent access by non-research personnel.  3) Using additional procedures, also 
used in our recent, pilot implementation of e-SBI for pregnant women, to safeguard the data such as:  i) Any 
electronic transmissions (e.g., from the study computer to the research staff) will not include personal information, 
but nevertheless will use encryption to ensure the maximum possible digital security; and ii) Data files on the study 
computers will downloaded and deleted daily to further protect privacy.   4)Identifying information obtained for 
identification and follow-up only information will be maintained separately from the data, used by research staff 
only, and will be physically and electronically locked when not in use.  5)Research staff will be trained on all 
procedures and protocols and closely supervised by Dr. Nayak (PI) to ensure confidentiality.  
 
b) If death data is being used, include risk to estate of deceased or living person by use of the death data. 
Does not apply 
 
 
c) If audio/video taping will be used, state if it could increase potential risk to subject's confidentiality. 
Audio-recordings will only be obtained for brief interviews on user experience following testing of the software 
during the preparatory period of the study.  The interviews will not ask women testing the computerized study program 
for any personal information and nor will any personal information be linked to the audio-recordings.  We will minimize 

Page 11 
 
risks to participant confidentiality by destroying the audio-recording after transcribing the recording, within one week of 
the interview. 
 
d) Describe how medical services will be provided if subjects suffer adverse mental or physical effects as result of 
research activity. If no services provided state clearly. 
 
  
We do not expect the e-SBI to increase alcohol use as it focuses on information on alcohol-related harms and 
outlines specific goals and a personalized plan to reduce drinking. The control group in our study receives only 
alcohol assessment, and not the intervention.  Assessment alone has been shown to reduce drinking in control 
groups in many prior studies.  Referrals for alcohol-related problems are available as part of usual care in the WIC 
clinic.  Hence participants in the control group who may need services will receive information and referrals for care 
in the same way as those in the study intervention group. 
 
The study could present risks for associated with screening and brief intervention, possibly increases in drug or 
tobacco use and depression as alcohol consumption decreases among participants. Such risks associated with alcohol 
intervention have not been evaluated in prior studies. Hence, there is no knowledge base to estimate the likelihood of 
these adverse outcomes. However, we will proactively address any need for further screening and intervention for 
participants who report drug use and significant depression, using established procedures used the WIC clinic.   
 
e) In the case of overseas research, describe qualifications/preparations that enable you to evaluate cultural 
appropriateness and estimate/minimize risks to subjects. 
 
Does not apply. 
 
f) Describe any less risky methods and why they are not being used. 
 
We include several procedures to minimize the minimal risks associated with the study, described 
previously.  As additional safeguards, we will include: 
Data Safety and Monitoring Plan. 
 
Sensitivity to ethical concerns, including anticipating any adverse events and proactively minimizing risks related 
with the proposed study, is of critical importance. Therefore, we will include oversight of all study procedures at 
multiple levels, including the Institutional Review boards at the Public Health Institute, and the California State 
Committee for Protection of Human Subjects, and seek guidance from our consultant and county program staff, 
particularly those who work with women at risk for substance use problems and poor mental health.    
Our trial does not involve drugs or biologics or devices and does not meet criteria for mandatory registration and 
result reporting requirements specified under Public Law 110-85 at www.clinicaltrial.gov. The trial proposed is a Phase I 
trial with an intervention with no known risks to participants. Therefore, it also does not meet criteria for requirements 
for the establishment of a data and safety monitoring board.  However, our trial is also registered on the 
www.clinicaltrial.gov website (see  https://clinicaltrials.gov/show/NCT02337361). Because the Contra Costa county WIC 
had been supported our study and provided a letter of support for our NIH grant application up until the end of February 
2015, the information on clinicaltrials.gov shows that WIC program as a participating organization. We will revise and 
update the study site information on this website after obtaining CPHS approval and, subsequently the needed approval 
for the State WIC program.   
A data safety and monitoring plan (DSM) is crucial to ensure safety of participants and is outlined next.  All study 
procedures and protocols will be reviewed by all relevant Institutional Review boards prior to any data collection and at 
any time changes are made to study procedures or protocols.  Dr. Nayak, (the PI) will monitor study implementation 
regularly through periodic observations at the study site, at least weekly meetings with the research staff, and monthly 
meetings with clinic staff or more frequently as needed.  She will monitor specific study procedures, including informed 
consent procedures, maximizing confidentiality of data collected, referrals for substance use and mental health care, 
and proactively address possible adverse events by ongoing training and supervision of research staff. Dr. Nayak is a 
licensed clinical psychologist in California and has over 19 years of clinical and research experience in various settings 
and cultures.  Her experience and qualifications as a mental health professional will help her identify and respond to any 
serious adverse event (SAE) expediently, and to plan for as many unanticipated problems as possible. Dr. Nayak will also 

Page 12 
 
consult with the county mental health and substance abuse counselors to address any adverse situations. We have 
already connected behavioral health service networks within the Sonoma County public health system and within La 
Clinica De La Raza and will seek their assistance to put together a DSM board to help minimize adverse events and to 
provide needed assistance to participants who may need substance use and mental health services.   
A research assistant will be on site at each site and maintain communication with WIC site staff when not on site in 
order to be alerted, as quickly as possible, to any adverse events that may occur between data collection times.  During 
data collection periods, Dr. Nayak will meet with the RAs at least twice a week and maintain daily contact with the RAs 
via telephone, email and text messaging.  All consent forms will include contact information for the PI and the 
chairperson of the Public Health Institute (PHI) IRB and will be provided to participants in printed form (printouts of 
relevant screens of the computerized study program – see storyboards for consent form screens).  Since the proposed 
study design includes two follow-ups and participants will be contacted between follow up periods to help reduce 
attrition, we will use these re-contact opportunities, with participant consent, to assess need for additional intervention 
due to increased alcohol consumption or mental health problems in the time periods between study follow ups and 
provide again the WIC referral information as needed.  
All adverse events and unanticipated problems will be reported to the CPHS and the Public Health Institute IRBs. 
Serious adverse events and unanticipated problems will be reported within 48 hours to the IRBS and the NIAAA project 
officer, who will also receive the annual reports to the IRBs that summarize all adverse study events.  
 
7. Benefits 
7. Benefits: (All project types) 
Are the benefits adequately described?  It should  
 
 
 Yes 
 No 
not include compensation. 
 
Describe the benefits, if any, to the subjects or to society that will be realized as a result of this project. Discuss the 
benefits that may accrue directly to the subjects as well as to society. If there is no direct benefit anticipated for the 
subjects, please state such. 
 
Potential benefits of the proposed research to human subjects and others 
 
The proposed study seeks to reduce excessive alcohol consumption among non-pregnant women of child bearing 
age as a primary prevention approach to reduce prenatal alcohol use.  It is expected to provide important information 
relevant to public health efforts to reduce Fetal Alcohol Spectrum Disorders and to improve the health of mothers and 
their infants.  The study includes a specific focus on cost-effective methods for screening and brief intervention (e-SBI) 
and on factors that affect the efficacy of e-SBI. Thus, the proposed study will impact not only public health efforts to 
reduce drinking in women of childbearing age women, but the larger body of science on the prevention of alcohol-
related harm.   
 
Because procedures to adapt e-SBI for use with non-pregnant women involves the input of WIC staff and local 
experts in maternal and child health, the proposed study will increase networking and collective action among 
professionals invested in improving women’s health. We have already connected with the bay area perinatal advocates 
and integrated their input into our study implementation and planned dissemination of findings.   
 
Explain why study risks are reasonable in relation to the potential benefits to subjects and to society. 
Importance of the knowledge to be gained 
 
There is an urgent need for cost-effective tools for delivering SBI to meet challenges to increase health care access 
for the implementation of the Affordable Care Act (ACA) in a weak economy with dwindling health care resources.  The 
proposed study will addresses barriers to recommended screening and brief intervention and to the prevention of 
drinking during pregnancy with a novel electronic SBI to reduce drinking in women before they become pregnant.  It will 
also test if drink size assessment alone can reduce drinking, providing data on possible cost effective interventions.  
Thus, the proposed study is of significance for the prevention of Fetal Alcohol Spectrum Disorders and for improved 
maternal and child health. Scientific knowledge on what may reduce or enhance e-SBI efficacy will also impact public 
health prevention efforts beyond that for childbearing age women and help further refine cost-effective strategies to 
reduce alcohol-related harm. 
   

Page 13 
 
8. Administrative Safeguards: (All project types) 
 
a. Are administrative safeguards for data security being met  
 Yes 
 No 
or is there justification for not meeting specific safeguards  
or providing an alternative safeguard? 
 
b. Has the individual(s) responsible for the security of this           
 Yes 
 No 
research data submitted a letter or statement that the  
organization is meeting the CPHS data requirements?  
The following requirements apply to all researchers, their contractors, and subcontractors with access to 
Personally Identifiable Data (PID). 
 
PID is defined as any data containing one or more of the 18 Health Insurance Portability and Accountability 
Act (HIPAA) Identifiers. 
 
If the researcher demonstrates that they are unable to comply with any of the requirements below, they 
may request an exception from these requirements. The researchers should indicate any measures that will 
be taken to address this requirement. The exception request should be made in the text box of the 
corresponding requirement. An exception will only be granted if the researcher can demonstrate that 
adequate alternative measures have been taken to minimize risks  so as to justify the exception. 
 
8. Administrative Safeguards 
 a) Describe the procedures for training all research staff, who have access to PID on privacy and security. Indicate if staff 
are required to sign a confidentiality statement related to general use, security and privacy 
 
Research Assistants (RA) will be trained in the use of the computerized study program, including the e-SBI and 
computerized assessments, all study documentation and follow up procedures, and requirements for ensuring 
confidentiality.  A study protocol and procedure manual which details privacy and security of personal identifiable 
information will be completed in the 2-month-preparatory period of the study.  Staff will complete the NIH human 
subjects training and a responsible conduct of research training online and also sign a confidentiality statement 
related to use, security and privacy of personal identifying information. Indeed, all ARG staff sign data standards 
forms for the storage, transfer and integrity of research data.  
b)Describe procedures, either background check or thorough reference check, for vetting staff, who will have access to 
PID. 
 
Research assistants for this project have not been hired yet.  The hiring process at our organization includes background 
checks and thorough reference checks.  Thus, all research staff who have access to PID will have undergone all necessary 
checks and required training in research with human subjects.   
 
 
c) Indicate whether you have obtained and submitted to CPHS a statement from the state agency or department you are 
receiving data from. That statement should include that the release of the desired data is legal and that the entity is 
willing to release the desired data to you, the researcher. 
 
 
The present study does not involve release of data from the participating agency to us.   However, we have requested 
initial review letters from the sites interested into participating in our study and expect to submit these letters by May 
22, 2015.  We have also requested an initial review letter from the State WIC program and expect to submit their letter 
on May 29th, 2015 prior to the June 5 meeting of the CPHS. 
 

Page 14 
 
d) Explain how you will ensure that data will not be reused or provided to any unauthorized person or entity 
(unauthorized means that the person or entity does not have a need to access the data for purposes of the research 
project approved by CPHS? 
Identifying information from participants will be stored separately from the study data in two separate electronic 
files: The first will list the WIC ID number and a study ID which is entered into the computerized study program at each 
assessment point to begin the program, the second file will list the study ID, participants name and contact 
information.  Both these electronic files will be zipped, encrypted, and password protected and stored on an encrypted 
external hard drive and backed up using secure VPN access to network drives at our organization, remaining in an 
encrypted form.  The external hard drive used to store identifying information requires a physical key in addition to 
electronic passwords to be accessed.  The physical key and the external hard drive will be locked in separate rooms at 
the study sites, each of which have controlled access areas and alarm monitoring.   
Files with identifying information will be accessed by research staff only by connecting the hard drive to a secure, 
study computer which has hard drive encryption and multiple layers of password-protection (boot up, log-in, file 
access).  Information will be accessed by research staff by connecting the external hard drive to a study laptop which will 
also be encrypted and thus password protected. However, no identifying information will be stored on the study laptop 
which will be removed from the site each day.  
 As an additional protection for identifying information provided by participants, we will apply to the NIH for a 
Federal Certificate of Confidentiality for our study. 
 
e) Indicate whether information will not be published that could possibly be used to identify an individual subject. 
Only group data will be published.  No information that can identify an individual subject will be presented at 
any venue or published in any form. 
 
f) Provide adequate justifications for the quantity of the data, the years and the variables being requested. Have you 
requested no more than the minimum necessary data to perform the research? 
Not applicable as the present study is not requesting from the participating agencies.  
 
 
g)Indicate if access to data limited only to those with a need to know for purposes of implementing or evaluating the 
research. 
Access to the data collected for this study will be limited to research staff. 
 
h)If applicable, justify why unique identifiers, other than social security numbers, cannot be used. 
Does not apply. 
 
 i)Describe appropriate and sufficient methods to protect the identity of individual subjects when small cells or small 
numbers and/or data linkage to another data set are involved in the research project. 
We will not report data on any groups with small cell sizes, e.g. women aged 43, and will combine data for cells 
with small numbers into larger groups (e.g. age 40 and older) where indicated 
 
 
j)If the data set is to be linked with any other data sets, identify all data sets and each of the variables to be linked, with 
justification for each linkage. If there is an extensive list, include the list as an attachment, in the Attachment Section. 
The study data will not be linked with any other data set. 
 
k) If a third party is being used to perform data matching, provided evidence of the third parties’ ability to protect PID, 
including third parties’ ability to comply with all the CPHS data security standards 
No third party will access or analyze the data collected in this study. 
  
l) Indicate that you will provide CPHS with a letter certifying that PID has been destroyed and/or returned to the data 
source once research is concluded. 
We will provide CPHS with a letter certifying that personal identifying information has been destroyed once the 
study has concluded. 

Page 15 
 
 
m) Include a certification from the Chief Information Officer, Privacy Officer, Security Officer or equivalent position of 
the researcher’s institution that CPHS Data Security Standards are met.A letter or statement assuring these standards 
are met from this individual on organizational letterhead may be included as an attachments in the Attachment Section. 
A letter from Jim Simpson, General Counsel at the Public Health Institute is included, to certify that CPHS 
Data Security Standards are met 
  
 
 

Page 16 
 
9. Physical Safeguards: (All project types) 
Are the physical safeguards for data security being met 
 
 Yes 
 No 
or is there justification for not meeting specific safeguards   
 N/A 
or providing an alternative safeguard? 
 
9. Physical Safeguards 
a)Indicate that research records and physical samples will be protected through the use of locked cabinets and locked 
rooms; PID in paper form will not be left unattended unless locked in a file cabinet, file room , desk, or office. 
All PID will be secured in locked rooms with controlled access.  Paper forms of PID, consent forms for the 
testing of the software will be scanned into electronic files within 24 hours. Paper consent forms will be 
secured in a locked cabinet in a locked office at the study sites until scanned. The electronic version of the 
consent forms will be placed in a single file and saved on the encrypted external drive that is manually and 
digitally secured. Once scanned, the paper consent forms will be destroyed by cross-cut shredding.   
 
b) State whether data/samples will be destroyed or returned as soon as it is no longer needed for the research project. 
PID will be destroyed once the study has concluded. 
 
c) If samples are to be retained, will they have personal identifies or be de-identified? 
Data collected for the study via the computerized study program is de-identified, 
 
d) Describe how you will ensure the PID in paper form is disposed of through confidential means, such as cross cut 
shredding or pulverizing. 
All PID in paper form will be destroyed using cross cut shredding. See text in section 9a above 
 
e) Describe how you will ensure that faxes with PID are not left unattended and fax machines are in secure areas. 
We will not receive or send any faxes with PID.   
 
  f) Indicate whether mailings of PID are sealed and secured from inappropriate viewing; mailings of 500 or more 
individually identifiable records of PID in a single package, and all mailings of PID to vendors/contractors/co-researchers 
are sent using a tracked mailing method, which includes verification of delivery and receipt, such as UPS, U.S. Express 
Mail, or Federal Express, or by bonded courier. 
No personal identifiable information will be mailed. 
 
g)State whether PID in paper or electronic form, e.g., stored on laptop computers and portable electronic storage media 
(e.g., USB drives and CDs), will never be left unattended in cars or other unsecured locations.  
No PID in any form (electronic or paper) will ever be left unattended in any unsecured location.  PID will never 
be saved on the laptops used by the RAs and all PID will be retained at the study site (WIC sites) in secured, controlled 
accessed areas only.   
 
 
h)Describe whether facilities, which store PID in paper or electronic form, have controlled access procedures, and 24 
hour guard or monitored alarm service. 
 
Both the Santa Rosa WIC and La Clinica De la Raza Fruitvale WIC sites, where the PID will be stored have controlled 
access procedures and 24 hour guard/ monitored alarm service 
Our organization, the Alcohol Research Group (ARG), has security systems in place which monitor access via a FOB, an 
electronic chip assigned to all ARG staff. ARG visitors must register at the reception area. Access to the building is 
monitored by security cameras and a security service vigils the facility 24 hours a day. 
 
i)Provide a description of whether all servers containing unencrypted PID are housed in a secure room with controlled 
access procedures. 
Only encrypted PID will be stored for this study on the external hard drive at the study site and backed up to 

Page 17 
 
the network at ARG.  
All ARG servers all locked in a server closet and are only accessible by the IT department staff.         
 
j) Indicate whether identifiers will be stored separately from analysis data. 
All personal information will be stored separately from the study data. 
 
k) State whether all disks with PID will be destroyed. 
All electronic files with PID will be destroyed at the conclusion of the study.  
 
10. Electronic Safeguards: (All project types) 
Are the electronic safeguards for data security being met 
 
 Yes 
 No 
or is there justification for not meeting 
specific safeguards 
 
 N/A 
or providing an alternative safeguard? 
 
10. Electronic Safeguards 
a)State whether all computer access be protected through the use of encryption, passwords, and other protections. 
Access to all ARG systems is protected through the use of encryption, strong passwords, and protections against 
intrusions via anti-virus and malware programs.  
All systems that are used to work with the PID data will be using a special hard drive that will house the data in a 
192-bit NIST certified AES Encryption method. The encryption method requires, as an additional security feature, the use 
of a removable hardware key which will be stored away to prevent unauthorized access. 
         
b. Indicate whether all workstations that contain PID have full disc encryption that uses FIPS 140-2 
compliant software. 
The use of the 192-bit NIST certified AES encrypted hard drive is mandatory. Hence PID will only be stored on devices 
that uses FIPS 140-2 compliant software 
 
c. Indicate if all laptops that contain PID have full disc encryption that uses FIPS 140-2 compliant software 
The use of the 192-bit NIST certified AES encrypted hard drive is mandatory. Laptops will not store PID. 
However all study laptops will have full disc encryption that uses FIPS 140-2 compliant software 
 
d.Note if PID on removable media devices (e.g. USB thumb drives, CD/DVD, smartphones, backup tapes) are encrypted 
with software which is FIPS 140-2 compliant. 
The use of the 192-bit NIST certified AES encrypted hard drive is mandatory to work and house PID data. Hence 
PID will only be stored on devices that have full disk eare encrypted with FIPS 140-2 compliant software. 
 
e. Indicate if all workstations, laptops and other systems that process and/or store PID have security patches applied in a 
reasonable time frame. 
All systems used for the study will have security patches applied in a reasonable time frame as per 
organizational standards. 
 
f)Indicate if sufficiently strong password controls are in place to protect PID stored on workstations, laptops, servers, 
and removable media. 
ARG is committed to maintain a high security standard and has very strong password controls.  All passwords 
must be ten characters long (minimum), must contain alpha-numeric and at least one special character (e.g. 
!@#$%^&*). In addition to this, passwords expire after 90 days and must be changed prior to expiration time. 
 
g)Indicate if sufficient system security controls are in place for automatic screen timeout, automated audit trails, 
intrusion detection, anti-virus, and periodic system security/log reviews? 
All study systems will have the screensaver feature turned on in order to automatically lock the computer after 
five minutes of inactivity and require that users enter credentials to log back in. In addition, ARG has a SonicWall firewall 

Page 18 
 
router that filters network traffic and prevents unauthorized access. All systems are protected by an anti-virus program 
which runs weekly scans to prevent malicious code from running.   
 
h)Explain whether all transmissions of electronic PID outside the secure internal network (e.g., emails, website access, 
and file transfer) are encrypted using software which is compliant with FIPS 140-2. 
The use of the 192-bit NIST certified AES encrypted hard drive is mandatory in our systems.  Thus all 
transmissions of electronic PID will use secure networks only (e.g. file transfer using vpn access to back up to ARG 
network drives) and therefore will be encrypted with FIPS 140-2 compliant software.   
        
 i)Note if PID in an electronic form will be accessible to the internet. 
At no time will the PID data be sent via the internet and hence will not be accessible to the internet. 
 
 j)When disposing of electronic PID, indicate whether sufficiently secure wiping, degaussing, or physical destruction will 
be used 
The following methods will be used to dispose of electronic PID:  
The “nuke method” which reformats the drive multiple times by filling it with 1s and 0s.  
Hard drives will be removed, tagged and degaussed. Any recorded media will also be tagged and degaussed. 
Degaussing uses strong magnets to rip-off any electronic data residing in the device, e.g., the hard drive and 
recorder. 
 
11. Conflict of Interest: (All project types) 
Are there any financial or other relationships of the 
 Yes 
 No 
researcher or institution that could be perceived  as 
 N/A 
as a conflict of interest described? 
 
 
11. Conflict of Interest 
Describe any financial or other relationships of the researcher(s) or the institution that could be perceived as 
affecting the objective conduct of the research, including the interpretation and publication of the findings. 
 
Financial relationships to be disclosed include but are not limited to the following: 
Present or anticipated ownership of stock, stock options, or other financial obligations of the source of 
funding. 
Receipt or expectation of payment of any sort in connections with papers, symposia, consulting, editing, 
etc. from the source of funding. 
The sale or licensing or anticipated sale or licensing of medical or other products or intellectual property, 
such as patents, copyrights, or trade secrets to the source of funding or other entities. 
Any past, present or anticipated receipt of money or other valuable consideration from the source of 
research funding by the researcher(s), the family of the researcher(s), the research institution, or by an 
institution in which the researcher(s) or the family of the researcher(s) has an interest as owner, creditor, or 
officer. 
 
Does any member of the study team, members' spouses, or members' dependent children have any 
significant financial interests related to the work to be conducted as part of the above-referenced project? 
 
NO 
 
I certify that all members of the study team have answered the financial interests question and only those 
individuals listed in the box above have disclosed any financial interest related to this study. 
YES 
 
 

Page 19 
 
 
12. Informed Consent: (Common Rule projects only) 
 Yes 
 No 
Is a description of the consent procedure included 
 
 
 
 N/A 
or a waiver consent requested? 
 
12. Informed Consent 
 
Provide a description of procedures to be used in obtaining and documenting the prior informed consent of 
participants. Further CPHS instructions and consent format may be found on the CPHS website link: 
http://www.oshpd.ca.gov/Boards/CPHS/index.html. 
 
Non-English versions of consent/assent forms or scripts must be submitted as attachments in the Attachment section , 
along with the curriculum vitae of the translators(s) and/or proof of certification of the translation firm. CPHS may reject 
poorly written documents or documents from translators lacking adequate proof of training or expertise. In general, 
Spanish translation should use formal language. 
 
 
CPHS may approve the use of a consent procedure which does not include, or which alters, some or all of the elements 
of informed consent. If a waiver or alteration of informed consent is being requested, provide information as to how all 
of the criteria below will be satisfied. 
Consent for the testing of the computerized study program will be obtained using paper forms.  The paper forms 
of this consent will be converted to electronic password-protected files stored separate from the study data.  Paper 
forms will be destroyed after being converted to electronic form (e.g. scanning), within 24 hours of completion of the 
paper form. 
Consent for the main study (screening and trial) will be obtained electronically and as part of the study 
computerized program.  Details regarding consent procedures are provided in sections 2 (procedures) and 6 (reducing 
risks).   
The English versions of both consent forms are attached.  We will translate the consent forms into Spanish once 
all study materials, including the consent forms are finalized and approved by the IRB.  The translator expected to work 
with us is a native Spanish speaker and has experience with translation as well as public health work. Her resume is 
attached with the application for review. 
 
13. Assent Background: (Common Rule projects only) 
 
 
Is a description of the informed assent procedure (for 
 Yes 
 No 
individuals age 7 to 17) included or a waiver of assent 
 
 
 N/A 
requested? 
 
13. Assent Background 
Provide a description of procedures to be used in obtaining and documenting the prior assent of participants. Further 
CPHS instructions and assent format may be found on the CPHS website link: 
http://www.oshpd.ca.gov/Boards/CPHS/index.html. 
 
Does not apply as the study will not include participants less than 18 years of age. A dummy file is attached. 
 
While the intent of informed assent is the same as that of informed consent, the informed assent must be written at a 
level that is understandable to potential participants who are children between the age of 7-17 years of age. Different 
informed assent forms may be needed if the study involves children of significantly different ages. The same headings 
must be used. Because some children cannot read through as long a form as an adult, assent forms may be shortened to 
facilitate reading and understanding by children. However, all of the required elements of the informed consent must 
still be adequately addressed. The CPHS website link to the format and additional instructions is : 
http://www.oshpd.ca.gov/Boards/CPHS/InstructionsforResearchers.pdf#Untitled (53).  
 
14. Health Insurance Portability and Accountability Act:  
 
 

Page 20 
 
(Common Rule and Information Practices Act projects only)  
 
If the data being requested is covered by HIPAA,  
 
 
 
 Yes 
 No 
is there a  HIPAA Authorization, HIPAA waiver request  
 
 
 N/A 
or the approval of another IRB attached?  
 
 14. Health Insurance Portability Accountability Act (HIPAA) 
To determine if data for this project is covered by HIPAA, respond to the four questions below. 
      1.  Will health information be obtained from a covered entity, known as a clearinghouse, such as Blue Cross, that 
processes or facilitates processing health data from another entity, including but not limited to state databases? 
 
Yes    No    
      2. Will the study involve the provision of healthcare by a covered entity, such as the UCD Medical Center? 
 
Yes    No    
      3.  If the study involves the provision of healthcare, will a health insurer or billing agency be contacted for billing or 
eligibility? 
 
Yes    No    
      4. Will the study involve other HIPAA criteria not listed above? 
 
Yes    No    
 
If you answered "YES" to any of the questions above, you are subject to HIPAA and must complete a HIPAA authorization 
or waiver request with your protocol. 
      Use table below ONLY when requesting waiver/alteration of HIPAA authorization. 
(the table is for attachments only) 
Text not included in online application as no space to enter text on the relevant screen 
HIPPA applies only when healthcare providers release protected health information.  We are not asking the WIC 
sites to provide us with any client data.  Personal information, such as the WIC ID, while protected health information, 
will be provided voluntarily by participants who provide informed consent.  Thus the data collected by our study, being 
provided by individuals themselves, does not fall under the purview of HIPAA. 
 
15. Assurance of Consistency between Grant Application  
and CPHS Protocol: (Common Rule projects only) 
 
 
 
 
 
 
a. If the project is funded by a grant, is the grant summary   
 Yes 
 No 
that addresses the questions in this section attached?  
 
 N/A 
 
b. Are the page numbers or sections of the grant and protocol 
 Yes 
No 
included? 
 
 
 
 
 
 
 
 N/A 
 
 
15. Assurance of Consistency between Grant Application and CPHS Protocol 
Is this project funded by a grant? 
 
Yes    No    
 
If 'Yes' is checked, please attach only the sections of the grant application, in Attachments, that address the questions 
below. List the page(s) in the grant application that confirm the consistency with the protocol. Also include that section, 
such as Subject Population, in the Protocol Information that confirms the consistency with the grant application. This 
section does not apply to contracts. 
 
a)The title of the project in the grant application and the research protocol are the same. If not explain why. 
Yes 
 
b)The specific aims of the project in the grant application and the research protocol are the same. If not, explain why. 
Please include the page number(s) where this information may be found on both documents. 

Page 21 
 
 
Yes. Specific aim 3 in this application is reworded slightly to make it more understandable for the general public.  
Specific aims in the grant application are on page 39 and in the purpose section of the research protocol. 
 
c)The research design/methods are the same in the grant application and the research protocol. If not, explain why. 
Please include the page number(s) were this information may be found on both documents. 
 
 
Minor differences exist between the grant application and the research protocol. The number of participants has 
increased from 150 in one site to 200 in two sites.  This is because our grant application was written with a letter of 
support from the Contra Costa County WIC program, proposing a single study site.  This program withdrew its support 
for the funded study at the end of March 2015 due to administrative and reorganization issues that would make their 
participation in the study difficult.  Other changes in the methods are related to changes in referrals for alcohol 
problems and depression being done via site staff to being done by the computerized program.  This is consistent with 
the program being a staff-free tool for low resource settings and reduces risks of stigma for participants. 
 
The relevant information is in the methodology and risks section of the grant application (page 45, 53 and 53) 
and under Subject population and Risks (item d) sections of the protocol. 
 
d)The inclusion criteria are the same in the grant application and the research protocol. If not, explain why. Please 
include the page number(s) were this information may be found on both documents. 
Inclusion criteria are the same.  However, we clarify in the research protocol that women who become pregnant 
during the course of the study will be excluded at follow up.  This is because the intervention provided is for non-
pregnant women. 
The relevant information is in the methodology section of the grant application (pages 46) and under screening 
procedures of the protocol. 
 
e)The human subjects protections, including vulnerable populations, are the same in the grant application and the 
research protocol. If not, explain why. Please include the page number(s) were this information may be found on both 
documents. 
 
Minor differences exist between the grant application and the research protocol, mostly due to changes in how 
referrals are made for participants who report alcohol-related problems and depression as explained in item c) above.  
The relevant  information is on pages 53 and 54 of the grant application and the Risks (item d) of the protocol. 
 
16. Attachments: (All project types) 
 
Required Documents: (All project types) 
 New Project Checklist 
 CV or resume of Principal Investigator (PI) and Co-PI 
 Data Security Letter from staff of the organization who is responsible for the security of the research data 
 Budget 
 Cover Letter 
 
Other Possible Items: (Please check all that apply) 
 Checklist for Research Involving Minors 
 Checklist for Research Involving Pregnant Women and Fetuses 
 Checklist for Neonates 
 Checklist for Research Involving Prisoners 
 Informed Consent Form (attach in section 12) 
 Informed Assent Form (attach in section 13) 
 Grant application 
 CV for translator 
 Surveys and questionnaires 
 Recruitment material 

Page 22 
 
 Other (Please specify):       
 
I. 
Translations: (Common Rule projects only) 
 
 
 
 
Are there or will there be any translations?   
 
 
 
 
 Yes 
 No 
Specify the language(s) Spanish  
 
 
 
 
 
 N/A 
 
II. 
Obligations: (All project types) 
Have the PI and Responsible Official checked this section? 
 
 
 Yes 
 No