Informed Consent for an Interview
Evaluation of CCC 1017 Program
Purpose of the Study. The purpose of this evaluation study is to provide information to the Centers for Disease Control and Prevention (CDC) about the experiences of a select group of 6 comprehensive cancer control programs that are focusing on Policy, System, and Environmental (PSE) change strategies to reduce the burden of cancer in their communities. This feedback will be used by CDC to improve the assistance they provide to communities and to guide their decisions about expanding the 1017 program approach. As a person involved in your community’s efforts to bring about lasting change in the burden of cancer, we are asking you to participate in an interview with members of the evaluation team. The purpose of the interview is to provide your perspective on the activities and achievements of local efforts to plan and implement PSE changes.
How the Study Will Be Conducted. Battelle is an independent contract research organization doing this evaluation under contract with the CDC. During site visits to each of six comprehensive cancer control programs, Battelle staff and possibly CDC staff will be speaking to ten to twelve individuals that serve in different capacities with respect to local PSE change efforts. After all the interviews are completed, a summary report will be prepared for each program.
Your participation in the interview is voluntary. Your decision to participate will not affect your relationship with CDC in any way. We will not quote you by name or attribute any statements to you in any report. Interview data will not be shared outside the CDC and Battelle evaluation team. Although we will take steps to protect against accidental disclosure of the data, we cannot promise that your identity will not be revealed. If at any time during this interview you want to stop, please say so and we will conclude the interview. You may also elect not to answer any questions you wish. We expect this interview to take about one hour to complete.
Do you have any questions about this evaluation study or about the interviews?
We are now going to ask for: 1) your consent to participate in an interview and 2) your consent to let us record the interview.
Consent to Participate.
Please print your name and sign below if you have been informed of and understand the above statements regarding this study, and agree to participate in the interview.
□ Yes, consent to participate provided
□ No, consent to participate not provided
Name of interviewee (please print):
Signature of interviewee: ________________________________ Date:
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In order to ensure an accurate record, we would like to make a digital audio recording of this interview. The recording will be used to create a transcript of the interview. The transcripts will be analyzed by members of the Battelle research team and the CDC 1017 evaluation team. All recordings will be destroyed at the end of the project.
Do you agree to allow us to record the interview?
Yes □
No □
If you have any questions regarding the evaluation or about how we safeguard the information that you share with us, please contact Ms. Carlyn Orians (206) 528-3320 or Dr. John Rose (919) 544-9154, ext. 102.
If you have any questions about your rights as a research participant, please contact Chair, Battelle Institutional Review Board, at 1-877-810-9530, extension 500.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Battelle |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |