CMS-10360 Consent Form

Attachment D. DRAFT Consent Form for Consumer Research
RESEARCH PARTICIPANT INFORMATION AND CONSENT FORM

RESEARCH

–

TITLE:

CONSUMER
MEASURES

HOSPITAL

SPONSOR:

The Centers for Medicare & Medicaid Services (CMS)
Baltimore, Maryland
United States

SITE(S):

TBD

QUALITY

Asking your permission to be in this research study
Thank you for coming today. You are being asked to be in a research study. Please read the
information below that tells about our research study. Be sure to ask if you have any questions.
Then, if you are willing to participate in the study, please sign your name at the bottom and give
the consent form back to us. We will give you a copy of the consent form to keep.
What is this study about, and what will you ask me to do?
The Department of Health and Humans Services (HHS) has a website that provides information
about hospital services. This website, called Hospital Compare, provides information on how
well hospitals care for their patients. When HHS puts information about hospitals on the website,
they want to make sure that it makes sense and helps people when making decisions about
hospital care. We’re asking your help today to review some new information that will soon be on
the website – we would like to hear your opinions about the information on the website.
Who is doing this study?
This study is being conducted by L&M Policy Research (L&M), a health services research
organization headquartered in Washington, DC. The study is funded by the Centers for
Medicare & Medicaid Services (CMS). CMS is part of the U.S. Department of Health and
Human Services (DHHS).
Will I be paid for my participation?
You will be paid $XX at the completion of the interview. If you choose to terminate the
interview, you will still be paid.
Do I have to participate in this study?
Your participation in this study is voluntary. You may decide not to participate or you may leave
the study at any time. Your decision will not result in any penalty or loss of benefits to which
you are entitled.
Will you be recording the discussion today?

Yes. With your permission, we plan to audiotape and videotape the discussion. If you prefer that
the session not be taped, please let us know. Giving your permission to be taped means that we
may share the tapes and information from the discussion with our study colleagues at CMS. We
may also 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 study.
How will you protect my confidentiality?
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.
Consent
I have read the information in this consent form. All my questions about the study and my
participation in it have been answered. I freely consent to be in this research study.

Your signature:
Today’s date:

Please print your name:

Appointment time:
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is CMS-10360. The time required to complete
this information collection is estimated to average
( 1.5 hours) or (90 minutes) per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.