Att 9_Informed Consent_12

Att 9_Informed Consent_12.18.13.docx

Case Studies to Explore Interventions to Support, Build, and Provide Legacy Awareness for Young Breast Cancer Survivors

Att 9_Informed Consent_12

OMB: 0920-1012

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Informed COnsent

Thank you for agreeing to speak with me today. ICF International, on behalf of the Centers for Disease Control and Prevention (CDC), is conducting case studies to explore programs that support Young Breast Cancer Survivors (YBCS). The purpose of this project is to determine: (1) the strategies programs are using to support YBCS; (2) the extent to which these strategies are effective; and (3) the extent to which these strategies are sustainable. We are talking with up to 12 programs from across the country that provide structured support services and have developed educational and awareness resources for YBCS.


We are conducting this interview with you because you have been identified as a person who can describe details about the management, design, and/or implementation of your organization’s YBCS program. Your opinions and thoughts are extremely valuable to our project, and there are no right or wrong answers. This interview is not meant to evaluate you; rather, it is meant to gain insights from you about how your program operates and is managed.


Our discussion will take approximately [select two hours for Program Director/Principal Investigator, select one hour for all other interviewees] of your time. We are planning to interview up to 10 individuals that are familiar with your program.


Information obtained through this interview will be treated in a secure manner and will not be disclosed, unless otherwise compelled by law. In addition, only the ICF project team will have access to data that can link your answers to you. There are no known risks to those who participate. The benefit of participating in this study is that your organization’s experiences will help inform recommendations for replicating promising YBCS interventions in other settings. Your responses will be reported in the aggregate. Two kinds of reports will be generated from this project: a site-specific summary report which will include findings from your program only, and a final report which will include the examination of the data collected across sites.


Your participation is completely voluntary. You may choose not to answer some of the questions or you may choose not to participate without penalty. You can choose to discontinue the interview at any time, for any reason. If you choose to stop participating in the interview, I will ask you whether you wish to withdraw all of your responses or allow the responses I have already collected to be used. If you choose to withdraw all of your responses, I will immediately discard all of your responses, and all ICF project team members have signed a non-disclosure agreement ensuring that they will not discuss any data collected outside of the project team.


As the interviewer, with your permission, I will audio record our conversation; an additional member of the ICF International project team will take notes during our discussion. We will use the information we learn from this interview to inform our site-specific summary report and our final report. This site-specific summary will be shared with ICF International project team members and CDC staff, as well as your Program Director/Principal Investigator, so that it can be reviewed for accuracy.


If you have questions about your rights as a participant, you may contact Sarah O’Dell, ICF Project Manager, by phone at 404-321-3211 or email at [email protected].


Before we begin the discussion, I would like to get verbal consent to proceed. Do you agree to participate in this interview?

  • Yes Thank you. I am confirming you are willing to answer questions during this discussion and will note your verbal consent. We also would like to record the conversation to make sure we don’t miss anything.

  • No Thank participant for his or her time and end conversation.


Do I have your permission to turn on the audio recorder?

  • Yes Thank you. Turn on recorder.

  • No Thank you. I will refrain from recording the session.


Do you have any questions for me before we begin?

Pause for participant response(s). Answer any questions the respondent has. Proceed to conducting the interview using the Interview Guide.

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