Patient Interview Phone Recruitment Script

Form Approved

OMB No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Attachment 5

Assessing Problem Areas in Referrals for Chronic Hematologic Malignancies and Developing Interventions to Address Them

HSC-SPH-07-0187

Patient Interview Phone Recruitment Script

Hello, my name is __________. I am calling from the University of Texas M.D. Anderson Cancer Center to ask for your participation in a behavioral research study in which we are exploring patient and provider experiences with hematologic malignancies. Our goal is to improve the quality of care for patients. By talking with you about your experiences and ideas, we hope to gain valuable information that may help us develop an educational program for patients and health care providers. We are conducting interviews with patients and doctors to better understand their experiences with cancers of the blood (i.e., Multiple Myeloma, Chronic Lymphocytic Leukemia, Lymphoma, Chronic Myelogenous Leukemia, and Myelodysplastic Syndrome). We are specifically interested in your experience with being diagnosed with a cancer of the blood and your health care experience during this time. In order to compensate you for your time and the valuable information you provide, you will receive a $30 American Express gift card.

Would you like to participate in this interview?

(If “Yes”): Great, Thank you. I would like to begin by reviewing the informed consent form and obtaining your consent to participate.

(If “No”): Is there a better time for me to call? (schedule appointment)

(For refusals): Thank you very much for your time.

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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)