Attachment 15 pediatric consent formFinal021608

Pediatric Influenza Project Verbal Consent Form

(English version)

Case ID _____________

Pediatric Influenza Hospitalization Surveillance Project

VERBAL CONSENT FORM (for parent/guardian)

Hello. This is __________ from the _____[state] Department of Public Health. May I speak to one of [child’s NAME] parents. We are working with the Centers for Disease Control and Prevention and other health departments to learn more about influenza disease or the flu. To do this, we are talking to parents of children who have been in the hospital with the flu. We want to look at things that may affect their illness and whether they were vaccinated against the flu.

Because your child was in the hospital for the flu beginning on _______[day admitted], I would like to ask you a few questions about whether they received flu vaccine this season or in the past. This will take about ten minutes. Your participation is voluntary and if you choose to refuse it will not affect any of your child’s medical care or benefits. All of your responses will be kept confidential as much as the law allows. You may refuse to answer any questions and may stop at any time. Answering these questions may help us create better childhood vaccination recommendations to prevent severe flu. There is no other benefit to your child for answering these questions. There is also no risk to your child. If you have any questions about the study, you may call _____[state contact] at the Department of Public Health at XXX-XXX-XXXX. Do you have any questions before I begin?

May I continue with this interview? □ Yes □ No

If YES, go to Appendix 5a.

If NO: Thank you for your time. Have a good day.

Name of person obtaining verbal consent: _______________________________

Date: _______________________________

Flesch-Kincaid: 7.0