Informed Consent Form for Adult Pretest Participation
Health Center Patient Survey
About the Survey
The Health Center Patient Survey is a research study being conducted by RTI International. The survey is sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA). The survey is about people who receive health care at places like this health center. The survey will try to find out what kinds of health problems people have and how well the health centers are meeting the needs of the people who use them. Before conducting the survey we want to find out whether the questions we plan to ask can be understood. The purpose of this “pretest” interview is to test how well the questions work. You are one of 69 people that RTI has chosen to participate.
Participation
If you agree to participate, you will be asked some questions about your health and the services that you receive at this health center. Some of the questions may be personal, such as questions about drug or alcohol use and your feelings. There also may be questions about HIV/AIDS. Most of the questions are about less sensitive things like health care received and whether you have certain health conditions like asthma or diabetes. As much as possible, try thinking out loud as you answer these questions. I will ask some follow-up questions to find out how you arrive at your answers. Please let me know if a question doesn’t make sense or makes you feel uncomfortable. Some people will get a shorter interview, while others will take a bit longer. The interview may last about 75 minutes
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not affect any services you may receive at the health center or from any other programs. If you do not want to answer some of the questions you are asked, that is okay. If you decide not to finish the questions, that is okay too. It is possible that some questions may make you uncomfortable or feel various emotions. If you need to take a break at any time, just let me know.
Benefits
There are not any direct benefits to you. However, you will be helping us learn more about how to conduct the Health Center Patient Survey. As noted, the survey is about the health needs of people who use health centers like this one.
Compensation for Participation
If you participate, you will be provided with $50 cash as a thank you for your time. On average, the interview will take about 75 minutes to complete.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you feel uncomfortable or upset. If you feel uncomfortable or upset you may ask the interviewer to take a break or skip any of the questions. The other risk is that someone might find out what you tell us during the interview. To avoid that, we will do the interview in private where no one can hear your answers. We will also create and use a number instead of your name to identify your interview. This will prevent anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it. Everyone involved in this research has signed an agreement stating they will protect the privacy of the information you provide. The information that you tell me will not be shared with anyone at this health center.
Questions
If you have any questions about this study, you may call Tim Flanigan at 1 (800) 334-8571 Ext 27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at 1 (866) 214-2043.
Do you have any questions that might help you decide whether or not you want to participate in the study?
By signing below, you are agreeing to participate. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ______________________________________________ Date: _________
Interviewer’s Signature: ______________________________________________ Date: _________
Informed Consent Form for
Parent/Guardian
Pretest Participation in Proxy Interview for
Accompanied Children
Health
Center Patient Survey
About the Survey
The Health Center Patient Survey is a research study being conducted by RTI International. The survey is sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA). The survey is about people who receive health care at places like this health center. The survey will try to find out what kinds of health problems people have and how well the health centers are meeting the needs of the people who use them. Before conducting the survey we want to find out whether the questions we plan to ask can be understood. The purpose of this “pretest” interview is to test how well the questions work. Your child, CHILD’S NAME, is one of 69 people that RTI has chosen to be included. Because CHILD’S NAME is less than 13 years old, we would like to ask you to answer questions about his/her health and the services that he/she receives at this health center.
Participation
If you agree to participate, you will be asked some questions about your child’s health and the services that he/she receives at this health center. Some of the questions may be personal, such as questions about your child’s drug or alcohol use and his/her feelings. There also may be questions about HIV/AIDS. Most of the questions, however, are about less sensitive things like health care received and whether or not your child has certain health conditions like asthma or diabetes. As much as possible, try thinking out loud as you answer these questions. I will ask some follow-up questions to find out how you arrive at your answers. Please let me know if a question doesn’t make sense or makes you feel uncomfortable. Some people will get a shorter interview, while others will take a bit longer. The interview may last about 75 minutes.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not affect any services your child or your family may receive at the health center or from any other programs. If you do not want to answer some of the questions you are asked, that is okay. If you decide not to finish the questions, that is okay too. It is possible that some questions may make you uncomfortable or feel various emotions. If you need to take a break at any time, just let me know.
Benefits
There are not any direct benefits to you or your child. However, you will be helping us learn more about how to conduct the Health Center Patient Survey. As noted, the survey is about the health needs of people who use health centers like this one.
Compensation for Participation
If you participate, you will be provided with $50 cash as a thank you for your time. On average, the interview will take about 75 minutes to complete.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you feel uncomfortable or upset. If you feel uncomfortable or upset, you may ask the interviewer to take a break or to skip any of the questions. The other risk is that someone might find out what you tell us during the interview. To avoid that, we will do the interview in private where no one can hear your answers. Also, we will create and use a number and instead of your name to identify your interview. This will prevent anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it. Everyone involved in this research has signed an agreement stating they will protect the privacy of the information you provide. The information that you tell me will not be shared with anyone at this health center.
Questions
If you have any questions about this study, you may call Tim Flanigan at 1 (800) 334-8571 Ext 27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at 1 (866) 214-2043.
Do you have any questions that might help you decide whether or not you want to participate in the study?
By signing below, you are agreeing to participate. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ______________________________________________ Date: _________
Interviewer’s Signature: ______________________________________________ Date: _________
Parent/Guardian Permission Form for
Accompanied Adolescent (Ages 13–17) Pretest
Participation
Health
Center Patient Survey
About the Survey
The Health Center Patient Survey is a research study being conducted by RTI International. The survey is sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA). The survey is about people who receive health care at places like this health center. The survey will try to find out what kinds of health problems people have and how well the health centers are meeting the needs of the people who use them. Before conducting the survey we want to find out whether the questions we plan to ask can be understood. The purpose of this “pretest” interview is to test how well the questions work. Your child is one of 69 people that RTI has chosen to participate.
Participation
If your child agrees to participate, he/she will be asked some questions about his/her health and the services that he/she receives at this health center. Some of the questions may be personal, such as questions about your child’s drug or alcohol use and his/her feelings. There also may be questions about HIV/AIDS. Most of the questions are about less sensitive things like health care received and whether your child has certain health conditions like asthma or diabetes. As much as possible, we will ask your child to try thinking out loud as he/she answers these questions. I will ask him/ her some follow-up questions to find out how he/she arrived at his/her answers. I will ask him/her to let me know if a question doesn’t make sense or makes him/her feel uncomfortable. Some people will get a shorter interview, while others will take a bit longer. The interview may last about 75 minutes.
Voluntary Participation
Your child may choose whether or not he/she would like to participate. If you choose not to give us permission or if your child chooses not to participate, it will not affect any services your child or your family may receive at the health center or from any other programs. If your child does not want to answer some of the questions he/she is asked, that is okay. If your child decides not to finish the questions, that is okay too. It is possible that some questions may make your child uncomfortable or feel various emotions. If he/she needs to take a break at any time, he/she should just let me know.
Benefits
There are not any direct benefits to you or your child. However, he/she will be helping us learn more about how to conduct the Health Center Patient Survey. As noted, the survey is about the health needs of people who use health centers like this one.
Compensation for Participation
In addition, if your child participates, he/she will be provided with $50 cash to thank him/her for his/her time. On average, the interview will take about 75 minutes to complete.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make your child feel uncomfortable or upset. If your child feels uncomfortable or upset, he/she may ask the interviewer to take a break or to skip any of the questions. The other risk is that someone might find out what your child told us during the interview. To avoid that, we will do the interview in private where no one can hear his/her answers. We will also create and use a number instead of your child’s name to identify your child’s interview. This will prevent anyone from finding out what your child’s answers were.
Your Child’s Privacy
Anything your child tells me is private. The privacy of his/her answers is very important, so let me say a little more about it. Everyone involved in this research has signed an agreement stating they will protect the privacy of the information provided. The information that your child tells me will not be shared with you or anyone at this health center.
Questions
If you have any questions about this study, you may call Tim Flanigan at 1 (800) 334-8571 Ext 27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at 1 (866) 214-2043.
Do you have any questions that might help you decide whether or not you want to give permission for your child to participate in the study?
By signing below, you are giving permission for your child to participate in the research described above. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You give permission for your child to participate.
You will be given a copy of this consent form to keep.
Name of Child: ______________________________________________
Parent/Guardian’s Signature: ______________________________________________ Date: _________
Interviewer’s Signature: __________________________________________________ Date: _________
Assent Form for Accompanied
Adolescent (Ages 13 – 17) Pretest Participation
Health Center Patient Survey
About the Survey
The Health Center Patient Survey is a research study being conducted by RTI International. The survey is sponsored by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA). The survey is about people who receive health care at places like this health center. The survey will try to find out what kinds of health problems people have and how well the health centers are meeting the needs of the people who use them. Before conducting the survey we want to find out whether the questions we plan to ask can be understood. The purpose of this “pretest” interview is to test how well the questions work. You are one of 69 people that RTI has chosen to participate.
Participation
(NAME OF PARENT/GUARDIAN) said it is okay for me to invite you to talk with me about your health and the services that you receive at this health center. If it is okay with you, I would like to ask you some questions. Some of the questions may be personal, such as questions about drug or alcohol use and your feelings. There also may be questions about HIV/AIDS. Most of the questions are about less sensitive things like health care received and whether or not you have certain health conditions like asthma or diabetes. As much as possible, try thinking out loud as you answer these questions. I will ask some follow-up questions to find out how you arrive at your answers. Please let me know if a question doesn’t make sense or makes you feel uncomfortable. Some people will get a shorter interview, while others will take a bit longer. The interview may last about 75 minutes.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not affect any services you may receive at the health center or from any other programs. If you do not want to answer some of the questions you are asked, that is okay. If you decide not to finish the questions, that is okay too. It is possible that some questions may make you uncomfortable or feel various emotions. If you need to take a break at any time, just let me know.
Benefits
There are not any direct benefits to you. However, you will be helping us learn more about how to conduct the Health Center Patient Survey. As noted, the survey is about the health needs of people who use health centers like this one.
Compensation for Participation
If you participate, you will be provided with $50 cash as a thank you for your time. On average, the interview will take about 75 minutes to complete.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you feel uncomfortable or upset. If you feel uncomfortable or upset you may ask the interviewer to take a break or skip any of the questions. The other risk is that someone might find out what you tell us during the interview. To avoid that, we will do the interview in private where no one can hear your answers. We will also create and use a number instead of your name to identify your interview. This will prevent anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more about it. Everyone involved in this research has signed an agreement stating they will protect the privacy of the information you provide. The information that you tell me will not be shared with anyone at this health center. Your parent/guardian will not see your answers, and we will not discuss any of your answers with them.
Questions
If you have any questions about this study, you may call Tim Flanigan at 1 (800) 334-8571 Ext 27743. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at 1 (866) 214-2043.
Do you have any questions that might help you decide whether or not you want to participate in the study?
By signing below, you are agreeing to participate. Please sign only if:
You understand the information about the research described in this consent form,
You have had all of your questions answered fully, and
You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ______________________________________________ Date: _________
Interviewer’s Signature: ______________________________________________ Date: _________
| File Type | application/msword |
| File Title | Informed Consent Form for Adult Pretest Participation |
| Author | tsf |
| Last Modified By | Windows User |
| File Modified | 2013-04-18 |
| File Created | 2013-04-18 |