Att 5_Treating Clinician Consent

Attachment 5: Treating clinician consent

Participant Consent Form

About the Project

You are invited to participate in an interview. Your participation will help public health planners understand your hospital’s current legionellosis surveillance and prevention practices and give feedback on draft materials related to legionellosis surveillance and prevention developed for use by treating clinicians. The interview will last no more than 60 minutes. You will receive $200 as a token of appreciation. A trained interviewer will lead the discussion. The results will help CDC better understand the current legionellosis diagnosis and prevention practices in hospitals and to gather feedback on draft materials designed to support these activities.

The interview will be conducted by telephone. We will audio record this interview. Members of the project team will listen to the tapes and write down what is said. Individual names will not be included in the written notes. We do not plan to allow anyone outside this project to listen or read anything that is recorded. All that you say will be kept private and secure to the extent permitted by law. Your name will not be used in any reports or publications resulting from the interview. We will make transcripts of the interviews and we will delete your name from the transcripts. The transcripts will be kept in a locked cabinet. We plan to destroy the transcripts by December 2017.

We do not foresee any risks to you from participating in this study. Your participation is voluntary and you do not have to answer any questions or discuss any issues that you do not want to discuss. You may stop participating at any time.

This project is sponsored by the Centers for Disease Control and Prevention. If you have any questions about this project, please call Rebecca Ledsky at 1-202-884-8814.

If you have questions about your rights as a participant in this project or think you have been harmed, please call 1-202-884-1450. Leave a message with your name and phone number, and someone will call you back as soon as possible.

We thank you for your time.

Participant Consent Form

My signature verifies that I have read the About the Project and understand my rights as a participant. I agree to participate in the interview. I understand that the interview will be about current legionellosis diagnosis and prevention practices in my hospital and to gather feedback on draft materials designed to support these activities. I agree to be audio-recorded. I understand that only the people working on this project will be given access to the audio-recording and transcription. I understand that CDC will not use my name or any other identifying characteristic in any report or other products that may result from this project.

Signature: ________________________________________________________

Name (Please print): ________________________________________________

Date: ___________________________