Hospital Outpatient Measures - Consumer Testing
Austin, TX January 26 & 27, 2010
Asking your permission to be in this research project
Thank you for coming today. Please read the information below that tells about our research project. Be sure to ask if you have any questions. Then, if you are willing to participate in the research project, please sign your name at the bottom and give the form back to us. We will give you a copy of the form to keep.
What is this project about, and what will you ask me to do?
Today we will be asking you to provide your opinions on information that will soon be posted on the Hospital Compare website. Based on the feedback that we get from you and others, we will make recommendations to the government about how to improve this information. This will take approximately 1.5 hours. As a thank you for participating, we will give you an incentive.
Who is doing this project?
This project is being conducted by L&M Policy Research (L&M), a health services research organization headquartered in Washington, DC. The project is funded by the Centers for Medicare & Medicaid Services (CMS), the federal agency in charge of the Medicare program. CMS is part of the U.S. Department of Health and Human Services (DHHS).
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 and you will receive the full incentive.
Will you be recording the discussion today?
Yes. With your permission, we plan to audio- and video-tape the discussion. We may reproduce what you say in other ways such as in reports and publications. When we share or reproduce information, however, we will be careful to never include your name. If a name is caught on tape, it will be erased before the tape or information is shared. The tapes will remain L&M property and will be destroyed one year after the end of the project.
How will you protect my privacy?
We will not use your name in connection with anything you say, and we will not give your name to anyone outside of the project.
What if I want more information?
Please ask us today if you have any questions.
If you have additional questions or concerns about this research study, please contact the director of the research project at L&M, Myra Tanamor, [email protected], 202-230-9029, 5411 Nebraska Ave NW, Washington, DC 20015.
Please sign below if you agree to participate
Signing your name below means that you are giving your “informed consent” to participate today. This means that you have read and understood the information on this form, you’ve had a chance to ask questions, and you are willing to participate under the conditions we have described. As discussed above, we will never identify you by name when your comments are used.
Your signature:_______________________________ Today’s date:____________________________
Please print your name:_________________________ Appointment time:________________________
| File Type | application/msword |
| File Title | Description of the proposed involvement of human subjects |
| Author | Tom Parrish |
| Last Modified By | CMS |
| File Modified | 2010-01-25 |
| File Created | 2010-01-25 |