2 Contact Information and Consent Form

ATTACHMENT 6:

Living with Lung Cancer Study

Contact Information Form

and

Consent for Contact

Form Approved

OMB No. 0920-xxxx

Exp. xx/xx/xxxx

“Living with Lung Cancer Study”

contact information Form

INSTRUCTIONS TO CLINIC STAFF:

Please send this form to the RTI Study Coordinator for follow-up.

NAME

HOME PHONE NUMBER ( )

WORK PHONE NUMBER ( )

CELL PHONE NUMBER ( )

E-MAIL OR OTHER CONTACT INFO

Would it be okay for us to leave a message on your phone?

Home: Y/N Work: Y/N Cell: Y/N

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Living with Lung Cancer Study

Consent for Contact

Your health care provider is working with the Centers for Disease Control and Prevention (CDC) and RTI International to conduct interviews with people living with lung cancer. These interviews are part of a study to learn more about the experience and needs of people living with lung cancer.

As someone identified as having been diagnosed with lung cancer over 6 months ago and between the ages of 30 and 80, we would like to talk to you about your experiences and any challenges you have faced in living with lung cancer. We will be completing a total of 27 interviews with people living with lung cancer.

If you are interested in participating in this study, your health care provider would need to share your contact information with a representative of RTI International, a nonprofit research organization, so they can talk to you further about participation. If you agree to be contacted, you are only saying you would like additional information. If you choose to participate in the study, you will be asked to provide a separate consent agreement. At any point, you may refuse to participate any further.

By signing this form, I agree to let someone contact me to learn more about this study. Upon learning more about the study, I will agree or refuse to participate in the study at that time.

NAME

(print)

Signature ___________________________ Date _____________________________