Attachment H -- AHRQ PSIC Informed Consent Form_07-14-08

Patient Safety Improvement Corps (PSIC) Interview

Agency for Healthcare Research and Quality

Individual Interview Consent Form

What is this project about and what will you ask me to do?

We are interested in finding out more about the lessons learned from the Agency for Healthcare Research and Quality’s Patient Safety Improvement Corps (PSIC) Training Program. We are conducting site visits to compile the lessons learned. Your experience in patient safety is critical and will provide information on the usefulness of the PSIC tools and techniques, as well as identify how organizations such as yours have used these concepts, tools, and techniques. This individual interview will take about one hour.

Who is doing this project?

This project is being conducted by the American Institutes for Research (AIR), a not-for-profit research organization. The project is funded by the Agency for Healthcare Research and Quality (AHRQ), a federal government agency.

Do I have to participate in this project?

No. It is your choice whether to participate or not. Also, you have the right to stop participating at any time, and you do not have to answer any questions that you don’t want to. If you choose not to participate or stop participating, there are no penalties.

What are the risks and benefits?

There are no anticipated or known risks in participating in this project. There are no direct benefits to you for participating in a site visit interview. In participating in this project, you will receive the opportunity to provide feedback to AHRQ about the PSIC training.

How will you protect my privacy?

To protect your confidentiality and privacy, your name/organization will not be connected with any statements you make during the interview or in any reports that result from this project unless expressly authorized by you. With your permission, we will be audio-recording the interview for reference, to ensure accuracy in capturing your thoughts. The recordings, transcripts, and notes will be destroyed no later than the end of the project.

More Information

If you have questions about this study, you can contact the Project Director, Laura Steighner, Ph.D. at [email protected], (202) 403-5064, or AIR, 1000 Thomas Jefferson Street NW, Washington, DC 20007. If you have concerns or questions about your rights as a participant, you can contact AIR’s Institutional Review Board (which is responsible for the protection of study participants) at [email protected], toll free at 1-800-634-0797 or c/o AIR, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304.

Consent to Participate

Do you understand the project described and agree to act as a participant in the study?	Yes No
Do you agree to have the individual interview recorded and to have the information gathered in the interview used in this project?	Yes No
Do you understand that you can withdraw your consent at any time and stop participating in the study without any prejudice to you?	Yes No
Do you understand that your name will not be associated with any of the reports or documents related to this project unless you expressly authorize us to do so?	Yes No
I request to be acknowledged in project-related documents

Signature: __________________________________________________

Print Name: __________________________________________________

Today’s date: __________________________________________________

Patient Safety Improvement Corps (PSIC) Interview

Agency for Healthcare Research and Quality

Individual Interview Consent Form

What is this project about and what will you ask me to do?

We are interested in finding out more about the lessons learned from the Agency for Healthcare Research and Quality’s Patient Safety Improvement Corps (PSIC) Training Program. We are conducting site visits to compile the lessons learned. Your experience in patient safety is critical and will provide information on the usefulness of the PSIC tools and techniques, as well as identify how organizations such as yours have used these concepts, tools, and techniques. This individual interview will take about one hour.

Who is doing this project?

This project is being conducted by the American Institutes for Research (AIR), a not-for-profit research organization. The project is funded by the Agency for Healthcare Research and Quality (AHRQ), a federal government agency.

Do I have to participate in this project?

No. It is your choice whether to participate or not. Also, you have the right to stop participating at any time, and you do not have to answer any questions that you don’t want to. If you choose not to participate or stop participating, there are no penalties.

What are the risks and benefits?

There are no anticipated or known risks in participating in this project. There are no direct benefits to you for participating in a site visit interview. In participating in this project, you will receive the opportunity to provide feedback to AHRQ about the PSIC training.

How will you protect my privacy?

To protect your confidentiality and privacy, your name/organization will not be connected with any statements you make during the interview or in any reports that result from this project unless expressly authorized by you. With your permission, we will be audio-recording the interview for reference, to ensure accuracy in capturing your thoughts. The recordings, transcripts, and notes will be destroyed no later than the end of the project.

More Information

If you have questions about this study, you can contact the Project Director, Laura Steighner, Ph.D. at [email protected], (202) 403-5064, or AIR, 1000 Thomas Jefferson Street NW, Washington, DC 20007. If you have concerns or questions about your rights as a participant, you can contact AIR’s Institutional Review Board (which is responsible for the protection of study participants) at [email protected], toll free at 1-800-634-0797 or c/o AIR, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304.

Consent to Participate

Do you understand the project described and agree to act as a participant in the study?	Yes No
Do you agree to have the individual interview recorded and to have the information gathered in the interview used in this project?	Yes No
Do you understand that you can withdraw your consent at any time and stop participating in the study without any prejudice to you?	Yes No
Do you understand that your name will not be associated with any of the reports or documents related to this project unless you expressly authorize us to do so?	Yes No
I request to be acknowledged in project-related documents