Attachment L Statements Of Informed Consent

ATTACHMENT L:

STATEMENTS OF INFORMED CONSENT

Nurse Statement of Informed Consent

Physician Telephone Statement of Informed Consent

Physician Web-based Statement of Informed Consent

NURSE STATEMENT OF INFORMED CONSENT

Nurse Statement of Informed Consent (Written Survey)

This survey funded by the Agency of Healthcare and Research Quality (AHRQ) is designed to provide insight into antibiotic prescribing practices in long-term care settings. We plan to aggregate information gathered through provider surveys and to disseminate the findings in published manuscripts and as presentations at national conferences. No direct quotes will be attributed to individual respondents. Your participation in the survey is voluntary and you may refuse to answer any question. No penalty or loss to you or to the patients you treat will result from refusal to participate or from survey discontinuation at any time. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). We expect this survey to take approximately fifteen to twenty minutes to complete.

If you have any questions about this survey you may contact Rosanna M Bertrand, PhD,

Project Director, Abt Associates Inc. at (617) 349-2556 OR Philip Sloane, MD, MPH, Project Co-Principal Investigator, the University of North Carolina at Chapel Hill at

(919) 966-3711. For questions about your rights as a participant in this study, please call Teresa Doksum, Abt Associates Institutional Review Board Administrator, at (671) 349-2896 (a toll call).

Your signature below indicates that you are agreeing to the terms stated in this informed consent.

Signature Date

PHYSICIAN TELEPHONE STATEMENT OF INFORMED CONSENT

Physician Statement of Informed Consent (Telephone Interview)

This survey funded by the Agency of Healthcare and Research Quality (AHRQ) is designed to provide insight into antibiotic prescribing practices in long-term care settings. We plan to aggregate information gathered through provider surveys and to disseminate the findings in published manuscripts and as presentations at national conferences. No direct quotes will be attributed to individual respondents. Your participation in the survey is voluntary and you may refuse to answer any question. No penalty or loss to you or to the patients you treat will result from refusal to participate or from survey discontinuation at any time. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). We expect this survey to take approximately fifteen to twenty minutes to complete.

If you have any questions about this survey you may contact Rosanna M Bertrand, PhD,

Project Director, Abt Associates Inc. at (617) 349-2556 OR Philip Sloane, MD, MPH, Project Co-Principal Investigator, the University of North Carolina at Chapel Hill at

(919) 966-3711. For questions about your rights as a participant in this study, please call Teresa Doksum, Abt Associates Institutional Review Board Administrator, at (617) 349-2896 (a toll call).

Do you agree to the terms stated in this informed consent?

PHYSICIAN WEB-BASED STATEMENT OF INFORMED CONSENT

Physician Statement of Informed Consent (Web-based Survey)

This survey funded by the Agency of Healthcare and Research Quality (AHRQ) is designed to provide insight into antibiotic prescribing practices in long-term care settings. We plan to aggregate information gathered through provider surveys and to disseminate the findings in published manuscripts and as presentations at national conferences. No direct quotes will be attributed to individual respondents. At the end of the survey, you will be asked if you would like to volunteer your name and contact information for a possible follow-up telephone interview to clarify survey data. Your participation is voluntary and you may refuse to answer any question. No penalty or loss to you or to the patients you treat will result from refusal to participate or from survey discontinuation at any time. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). We expect this survey to take approximately fifteen to twenty minutes to complete.

If you have any questions about this survey you may contact Rosanna M Bertrand, PhD,

Project Director, Abt Associates Inc. at (617) 349-2556 OR Philip Sloane, MD, MPH, Project Co-Principal Investigator, the University of North Carolina at Chapel Hill at

(919) 966-3711. For questions about your rights as a participant in this study, please call Teresa Doksum, Abt Associates Institutional Review Board Administrator, at (617) 349-2896 (a toll call).

By completing and submitting this web-based survey, you are agreeing to the terms stated in this informed consent.