Attachment E -- Consent Form

S

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

TUDY CONSENT FORM

The Agency for Healthcare Research and Quality, an agency of the U.S. Department of Health and Human Services, has asked Westat to gather information on the public’s beliefs and impressions of Health Information Technology, such as the use of computers in healthcare. The discussion in which you will be participating may provide ideas and guidance for future developments in Health Information Technology.

The information you provide in the interview will be treated as confidential. You will not be identified by name in any of our reports. Your information will be combined with information from other respondents and presented in summary form for our internal analysis. Individuals are assured of the confidentiality of their responses under Section 934(c) of the Public Health Service Act, 42 USC 299c-3(c) and under 42 U.S.C. 1306, and 20 CFR 401 and 4225 U.S.C.552a (Privacy Act of 1974).

We will need up to two hours of your time. You will be paid $75 cash after the interview.

The group’s discussion will be audio-tapes and video-taped and it may be observed by other researchers on the project. Recordings allow us to carefully review the discussion and draw the proper conclusions. When not in use, the videotape will be stored in a locked cabinet and be inaccessible to persons not working on this project. The videotape and all identifying materials for this study will be destroyed by April 1, 2009.

Your participation is voluntary and you have the right to leave at any time. You may also decline to answer any questions that we ask.

The researcher will be happy to answer any questions you have about the study.

If you agree to participate, please sign below.

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I have read and understand the statements above. I consent to participate in this study.

___________________________________ ___________________________

Participant's signature Date

___________________________________

Participant's printed name

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Researcher's signature

Public reporting burden for this collection of information is estimated to average two hours per response, the estimated time required to complete the discussion. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.