Asking your permission to be in this research project
If you are willing to participate in the research project after reading this description, 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?
The Agency for Healthcare Research and Quality (AHRQ) is funding the American Institutes for Research to implement and evaluate using the Loeb Criteria Communication and Order form as a means of standardizing antibiotic use in long term care settings. We are conducting interviews to help us understand how the form is being used. This interview will take from 30 minutes to an hour.
Who is doing this project?
This project is being done by the American Institutes for Research (AIR), a non-profit social science research organization headquartered in Washington, DC and with offices in MD, CA and NC. The project is funded by the Agency for Healthcare Research and Quality.
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.
Will you be recording the discussion today?
Yes. With your permission, we plan to record the interview, only to make sure we are collecting everything you say. The recordings will remain AIR property and will be destroyed no later than one year after the end of the project.
How will you protect my privacy?
We will not use your name or the name of your nursing home in connection with anything you say, and we will not give your name to anyone outside of the project. In addition, we will ensure that no statements may indicate which nursing home is being described.
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 AIR, Dr. Steven A Garfinkel, [email protected], 919-918-2306, 101 Conner Drive, Suite 301, Chapel Hill, NC, 27514.
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected] toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please sign below if you agree to participate
Your signature:_______________________________ Today’s date:______________________
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| File Type | application/msword |
| Author | Elizabeth Frentzel |
| Last Modified By | william.carroll |
| File Modified | 2011-01-13 |
| File Created | 2010-11-15 |