#18_Att_B CT Informed Consent Form

Attachment B OMB# 0925-0046-18

Expiration Date: 1/31/2010

Informed Consent Form

Identification of Project	Online Needs Assessment Survey to Inform the Development of Tools and Materials to Further NCI-designated Cancer Centers’ Clinical Trial Accrual Practices
Statement of Age of Subject	I state that I am at least 18 years of age, in good physical health, and wish to participate in a program of research being conducted by Holly Massett, Ph.D. in the Office of Market Research and Evaluation of the National Cancer Institute, Bethesda, MD 20742.
Purpose	The National Cancer Institute (NCI) proposes conducting a Web-based survey with representation from a range of personnel at NCI-designated cancer centers to help inform the development of materials and tools that will support increased accrual to clinical trials. The goal of this formative needs assessment is to better understand the prevalence of promising practices to support accrual to clinical trials. These assessment data will be collected from and analyzed among and within responding institutions. The current research design will focus on collecting data from persons in the cancer centers who have day-to-day responsibility for clinical trial accrual and who are in a position to know about how accrual functions in their center.
Procedures	NCI proposes a Web-based survey. NCI proposes including all 65 NCI-designated cancer centers in the sampling frame. We will send survey invitations to the following persons in each cancer center: Clinical trial outreach coordinator Director of Hematology Oncology Department Lead Research Nurse in Hematology Oncology The proposed Web-based needs assessment survey will consist predominantly of close-ended questions. To provide contextual insights, several open-ended questions will also be asked. The approximate time required to complete the survey will be 20 min.
Confidentiality	All information collected in this study will be kept confidential, to the extent permitted by law. I understand that the data I provide will be grouped with data others provide for the purpose of reporting and presentation and that my name will not be used. I understand that the group discussion will be audiotaped, but my voice will not be played to others besides the research team without my written permission.
Risks	I understand that the risks of my participation are expected to be minimal in nature.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	I understand that this study is not designed to help me personally but that the investigators aim to learn about the range of consumers’ communications preferences, information seeking practices, and unmet needs. I am free to ask questions or withdraw from participation at any time and without penalty.
Contact Information of Investigators	Name: Holly Massett Position: Director of the Office of Market Research and Evaluation Telephone: 301-594-8193 Email: [email protected]

Printed Name of Research Participant _____________________________

Signature of Research Participant ________________________________

Date______________________