Attachment H - Written Informed Consent for Focus Groups

Attachment H:

Written Informed Consent Form For Focus Groups

The Agency for Healthcare Research and Quality (AHRQ) is conducting an assessment of the acceptance of the Emergency Severity Index (ESI) by Emergency Departments and the satisfaction with and usefulness of the ESI training materials developed by AHRQ, which include an implementation handbook (Emergency Severity Index, Version 4) and companion DVDs. AHRQ is collaborating with the National Opinion Research Center (NORC) – a not-for-profit research organization at the University of Chicago – to conduct this study.

The purpose of the research study is to: 1) measure the acceptance of the ESI by emergency departments and others; 2) measure the satisfaction with the ESI training materials, including their presentation, content, and clarity; 3) determine the extent that the ESI has improved emergency services, surge planning and preparation; 4) compare usefulness of the ESI with other similar triage tools; and 5) determine what improvements users would like to see in the next version of the ESI. This assessment will enable AHRQ to further improve the ESI and its training materials, and better encourage hospitals to use the ESI as their triage tool.

 

We are asking you to contribute to this study by participating in a focus group. Completing the focus group will take no longer than 90 minutes. There are no foreseeable risks to your participation. Your participation in this study is completely voluntary. You have the right to withdraw from the focus group at any time. If at any point during the focus group you wish to withdraw as a participant, please notify the Facilitator. Note, however, that your previous responses will remain part of the record. In addition, you are free to refrain from answering any questions or commenting on any discussion topics that may arise.  Whether or not you choose to participate in the focus group, or decide to withdraw at any point, will not affect you in any way.

NORC would like to audio record the focus group in order to help us to take comprehensive notes of this discussion. We will not share the audio tape with any other party, and all tapes will be destroyed after we have reviewed them. All data collected during the focus group will remain completely confidential.  We are not collecting your name or any other potentially identifying information.

If you have questions about your rights as a participant in this research project, please call the NORC Institutional Review Board Administrator, Kathleen Parks, at (866) 309-0542. If you agree to participate, please sign and date the statements below, indicating your informed consent. 

 

“I have read and understand the information presented in this document, and have been given the opportunity to ask any questions. I give my permission to be recorded using audio equipment during this research study. I understand that the recordings will be reviewed for the purposes of this study and destroyed shortly thereafter. I freely choose to participate in this research study, and understand my right to withdraw as a participant at any time.”

Print name

of participant:___________________________________________ Date______________

Signature

of participant: ___________________________________________ Date______________

Signature of individual

Obtaining consent:________________________________________ Date______________

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. 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.