Attachment G2 Physician Informed Consent [2]

ATTACHMENT G2:

INFORMED CONSENT FORM FOR PHYSICIANS

Informed Consent Form for Physicians

Physician Cancer Screening Discussion
Consent Form

The Centers for Disease Control and Prevention (CDC) is interested in learning about primary care physicians’ opinions and practices regarding cancer screening. CDC has asked RTI International (RTI), a nonprofit health research organization, to conduct several discussion groups of approximately six to eight primary care physicians each. These will be conducted over the telephone in a conference call format. The purpose of this research study is to ask physicians to identify factors that impact their cancer screening practices. This information will be used to describe the issues related to cancer screening in primary care practices and improve efforts in cancer prevention and control in primary care.

You have been selected from a list of primary care physicians to participate in one of the group discussions. Your participation is entirely voluntary. Each group discussion will take approximately 75 minutes and will consist entirely of primary care physicians. You will receive $175 for your participation and time in one group discussion. Risks associated with your participation are minimal but may involve a loss of confidentiality, should you know anyone participating. You may not benefit personally by participating with the exception of gaining information from other practitioners during the discussion. Any information you would provide will not be associated with your name, and all data will be kept private in accordance with federal laws. RTI researchers who are conducting the study will not reveal the names or other identifying information of individual physicians to anyone. The sessions will be recorded; names and other identifying information will not be included in any transcriptions or reports. RTI will permanently erase all tapes upon completion of the analysis. You have the right to refuse to answer any of the questions asked in your group discussion. You have the right to stop participating at any time. RTI researchers may contact participants again for clarification of comments made in the group discussions.

If you have any questions about this study, please contact Cindy Soloe, the RTI Study Coordinator, at [email protected] or 1-800-334-8571, extension 3363 or Dr. Julia Kish Doto, RTI Project Director, at 1-800-334-8571, extension 8280, [email protected]. If you have any questions about your rights as a study participant, you can call RTI’s Office of Research Protection at 1-866-214-2043 (a toll-free number). You may also contact CDC’s Acting Deputy Associate Director for Science at 1-800-584-8814 and leave a message with your name, phone number, and refer to CDC protocol # 5119, and someone will call you back.

Please keep one copy of this consent form for your records. If you agree to be a part of our session, please sign below.

Signature ________________________

Date ________________________