Consent Form

All Age Influenza Hospitalization Surveillance (Flu Hosp) Project
Consent Form

Form Approved
OMB No. 0920-0978
Exp. Date 08/31/2016

Consent Form (for patient/proxy interview ONLY)
Influenza Hospitalization Surveillance Project
VERBAL CONSENT FORM
Hello. My name is __________ from the _____[state] Department of Public Health. May I speak to ______
[patient’s name /parent of [child’s name] ] . We are working with the Centers for Disease Control and Prevention
and other health departments to learn more about influenza disease or the flu. To do this, we are talking to people
who have been in the hospital with the flu. We want to look at things that may affect their illness and whether they
were vaccinated against the flu.
Because you/your child [or NAME if speaking with proxy] were in the hospital for the flu beginning on
_______[day admitted], I would like to ask you a few questions about whether you/your child [or NAME if
speaking with proxy] received the flu vaccine this season. This will take about five minutes. Your participation is
voluntary and if you choose to refuse it will not affect any medical care or benefits you receive. All of your
responses will be kept confidential as much as the law allows. You may refuse to answer any questions and may
stop at any time. This information will help [State/Local Health Department] and CDC better describe influenzaassociated hospitalizations. Additionally, this information may help us improve vaccination recommendations for
flu and better protect the public’s health. There is no other benefit to you for answering these questions. There is
also no risk to you. If you have any questions about the study, you may call _____[state contact] at the Department
of Public Health at XXX-XXX-XXXX. Do you have any questions before I begin?
May I continue with this interview?

□ Yes

□ No

If YES, go to Appendix F.
If NO: Thank you for your time. Have a good day.
Name of person obtaining verbal consent:
Date:

_______________________________
_______________________________
Flesch-

Kincaid: 7.7

Case and Proxy Identifying Information
Influenza Hospitalization Surveillance Project
Patient’s:
Last name________________ First name____________ Initial__
Date of birth: ____/____/______
Phone_____________

Proxy’s:
Last name________________First name____________ Initial__
Phone_________________
Relationship to case patient _________________________
Note to collaborators: This is for your records only. Do not send this information to CDC. Keep
this information in a secure locked place.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).