Attachment 16 adult consent formFinal21608

Adult Flu Hosp Consent Form

(English version)

Case ID _____________

Consent Form (for patient/proxy interview ONLY)

Adult Influenza Hospitalization Surveillance Project

VERBAL CONSENT FORM

Hello. This is __________ from the _____[state] Department of Public Health. May I speak to ______ . 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 people who have been in the hospital with the flu. We want to look at things that may affect their illness, including the medicines they take, and whether they were vaccinated against the flu.

Because you [or NAME if speaking with proxy] were in the hospital for the flu beginning on _______[day admitted], I would like to ask you a few questions about whether you received the flu vaccine this season. This will take about five minutes. Your participation is voluntary and if you choose to refuse it will not affect any medical care or benefits you receive. 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 vaccination recommendations for the flu. There is no other benefit to you for answering these questions. There is also no risk to you. 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 or NO: May I review your flu hospital records and write down which medicines, including any cholesterol medicines or statins, you were taking when you became ill? □ Yes □ No ]

If YES, go to Appendix C.

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

Name of person obtaining verbal consent: _______________________________

Date: _______________________________

Flesch-Kincaid: 7.7