Attachment 3-INFORMED CONSENT FUNDING SOURCE Q_v2(11-11-2011)

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

Attachment 3: Funding Source Questionnaire Informed Consent

The National Institutes of Health Office of Performance and Evaluation has funded the National Institute of Nursing Research (NINR), with assistance from NOVA Research Company (NOVA), to conduct an evaluation needs assessment on end-of-life and palliative care (EOL PC) research topics and funding trends. Your participation in the needs assessment is important because the data collected from this evaluation will serve as a major milestone in identifying future directions to advance EOL PC research capacity.

The purpose of this brief questionnaire (7 questions) is to collect information on funding sources that supported published study findings. Authors of EOL PC research publications for whom a funding source is unknown (i.e., not listed with their publications or the funding source was unclear in the manuscript description) are being contacted to supply this information through the completion of a brief questionnaire about the study (e.g., funding agency). Because you are one of these authors, we request that you complete this questionnaire which should take approximately 5 minutes.

• Information provided by respondents will be kept private. Your personal identity will be protected. All answers will be assigned a confidential ID number so that your name and any other personal information will not be directly linked.

• Data files will be stored securely so that outsiders cannot see them. Personal identifying information will be stored separately from the questionnaire responses. After the study is completed, your name and contact information will be destroyed.

• Your answers will be collated with the responses of other participants and analyzed in aggregate. No one will be identified in study reports or publications which may be published or presented publicly.

Your participation is voluntary. You can choose to not answer questions and stop your participation at any time without consequence to you. We believe that your participation in the survey has very low risk of harm to you.

NINR is authorized to conduct this study under section 42 USC 285q of U.S. Law. If you have questions about this study or your participation, please contact Dr. Amanda Greene by email at [email protected] or by phone at (301) 496-9601.

If you decide to participate in the study, please check the “I Accept” button below. By giving consent, you indicate that you have read this form and that you understand what you are consenting to and your rights as a research participant.

I Accept

I do NOT Accept