CPCC_#20_Attach4 In-lab Consent Form

Attachment #4 Informed Consent Form

Identification of Project	Cancer Prevalence and Cost of Care Projections Website
Statement of Age of Subject	I state that I am at least 18 years of age, in good physical health, and wish to participate in a program of research being conducted by Robin Yabroff and Susan Scott of the DCCPS of the National Cancer Institute, Rockville, MD 20852.
Purpose	The purpose of this research is to test usability of the Cancer Prevalence and Cost of Care Projections website.
Procedures	Participants will be asked to work with the interface, perform certain tasks, and answer questions about the experience. The total time involved, including instructions will be no more than 60 minutes.
Confidentiality	All information collected in this study will be kept private to the extent permitted by law. I understand that the data I provide will be grouped with data others provide for the purpose of reporting and presentation and that my name will not be used.
Risks	I understand that the risks of my participation are expected to be minimal in nature.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	I understand that this study is not designed to help me personally but that the investigators hope to improve the usability of the Cancer Prevalence and Cost of Care Projections website in order to make the experience of future participants using this website easier. I am free to ask questions or withdraw from participation at any time and without penalty.
Contact Information of Investigators	Name: Robin Yabroff and Susan Scott Position: Office of the Associate Director of DCCPS Telephone: 301-594-1723 and 301-496-5410 Email: [email protected] and [email protected]

Printed Name of Research Participant _____________________________

Signature of Research Participant ________________________________

Date______________________

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