Attachment
G
Consent Form for Interviews
Asking your permission to be in this research project
If you are willing to participate in the research project after reading this description, please sign your name at the bottom and give the form back to us. We will give you a copy of the form to keep.
What is this project about and what will you ask me to do?
The Agency for Healthcare Research and Quality (AHRQ) is funding the American Institutes for Research to implement and evaluate the Guide for Nursing Home Antimicrobial Stewardship (the Guide) as a means of standardizing antibiotic use in long term care settings. We are conducting interviews to help us understand how the Guide is being used. This interview will take from 30 to 60 minutes.
Who is doing this project?
This project is being led by the American Institutes for Research (AIR), a non-profit social science research organization. AIR is working with the Texas A & M University of Health Science Center, TMF Health Quality Institute (the Texas Quality Improvement Organization) University of Pittsburgh, University of Wisconsin, and experts in infectious diseases in long-term care settings.
Do I have to participate in this project?
No. It is your choice whether to participate or not. Also, you have the right to stop participating at any time, and you do not have to answer any questions that you don’t want to. If you choose not to participate or stop participating, there are no penalties.
Will you be recording the discussion today?
Yes. With your permission, we plan to record the interview, only to make sure we are collecting everything you say. The recordings will remain AIR property and will be destroyed no later than one year after the end of the project.
How will you protect my privacy?
We will not use your name or the name of your nursing home in connection with anything you say, and we will not give your name to anyone outside of the project team. In addition, we will ensure that no statements may identify which nursing home is being described.
What if I want more information?
Please ask us today if you have any questions.
If you have additional questions or concerns about this research study, please contact the director of the research project at AIR, Elizabeth Frentzel, MPH, [email protected], (781) 373-7079, 201 Jones Road, Waltham, MA 02451
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected] toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please sign below if you agree to participate
Your signature:_______________________________ Today’s date:______________________
Asking your permission to be in this research project
If you are willing to participate in the research project after reading this description, please verbally agree. Please keep this form for future reference.
What is this project about and what will you ask me to do?
The Agency for Healthcare Research and Quality (AHRQ) is funding the American Institutes for Research to implement and evaluate using the Guide for Nursing Home Antimicrobial Stewardship (the Guide) as a means of standardizing antibiotic use in long-term care settings. We are conducting interviews to help us understand how the Guide is being used. This interview will take from 30 to 60 minutes.
Who is doing this project?
This project is being led by the American Institutes for Research (AIR), a non-profit social science research organization. AIR is working with the Texas A & M University of Health Science Center, TMF Health Quality Institute (the Texas quality improvement organization), University of Pittsburgh, University of Wisconsin, and experts in infectious diseases in long-term care settings.
Do I have to participate in this project?
No. It is your choice whether to participate or not. Also, you have the right to stop participating at any time, and you do not have to answer any questions that you don’t want to. If you choose not to participate or stop participating, there are no penalties.
Will you be recording the discussion today?
Yes. With your permission, we plan to record the interview, only to make sure we are collecting everything you say. The recordings will remain AIR property and will be destroyed no later than one year after the end of the project.
How will you protect my privacy?
We will not use your name or the name of your nursing home in connection with anything you say, and we will not give your name to anyone outside of the project team. In addition, we will ensure that no statements may identify which nursing home is being described.
What if I want more information?
Please ask us today if you have any questions.
If you have additional questions or concerns about this research study, please contact the director of the research project at AIR, Elizabeth Frentzel, MPH, [email protected], (781) 373-7079, 201 Jones Road, Waltham, MA 02451
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected] toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please verbally state if you agree to participate.
Asking your permission to be in this research project
If you are willing to participate in the research project after reading this description, please verbally agree. Please keep this form for future reference.
What is this project about and what will you ask me to do?
The Agency for Healthcare Research and Quality (AHRQ) is funding the American Institutes for Research to implement and evaluate using the Guide for Nursing Home Antimicrobial Stewardship (the Guide) as a means of standardizing antibiotic use in long-term care settings. We are proactive discussions to help us understand how the Guide is being used, to provide technical assistance, and to understand how to improve the Guide. This discussion will take up to 60 minutes. We will be holding these discussions once a month.
Who is doing this project?
This project is being led by the American Institutes for Research (AIR), a non-profit social science research organization. AIR is working with the Texas A & M University of Health Science Center, TMF Health Quality Institute (the Texas quality improvement organization), University of Pittsburgh, University of Wisconsin, and experts in infectious diseases in long-term care settings.
Do I have to participate in this discussion (research study)?
No. It is your choice whether to participate or not. Also, you have the right to stop participating at any time, and you do not have to answer any questions that you don’t want to. If you choose not to participate or stop participating, there are no penalties.
Will you be recording the discussion today?
Yes. With your permission, we plan to record the interview, only to make sure we are collecting everything you say. The recordings will remain AIR property and will be destroyed no later than one year after the end of the project.
How will you protect my privacy?
We will not use your name or the name of your nursing home in connection with anything you say, and we will not give your name to anyone outside of the project team. In addition, we will ensure that no statements may identify which nursing home is being described.
What if I want more information?
Please ask us today if you have any questions.
If you have additional questions or concerns about this research study, please contact the director of the research project at AIR, Elizabeth Frentzel, MPH, [email protected], (781) 373-7079, 201 Jones Road, Waltham, MA 02451
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected] toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please verbally state if you agree to participate.
Asking your permission to be in this research project
If you are willing to participate in the research project after reading this description, please verbally agree. Please keep this form for future reference.
What is this project about, and what will you ask me to do?
The Agency for Healthcare Research and Quality (AHRQ) is funding the American Institutes for Research to implement and evaluate using the Guide for Nursing Home Antimicrobial Stewardship (the Guide) as a means of standardizing antibiotic use in long-term care settings. We are conducting interviews to help us understand how the Guide was being used and how to improve the Guide. This interview will take up to 60 minutes.
Who is doing this project?
This project is being led by the American Institutes for Research (AIR), a non-profit social science research organization. AIR is working with the Texas A & M University of Health Science Center, TMF Health Quality Institute (the Texas quality improvement organization), University of Pittsburgh, University of Wisconsin, and experts in infectious diseases in long-term care settings.
Do I have to participate in this project?
No. It is your choice whether to participate or not. Also, you have the right to stop participating at any time, and you do not have to answer any questions that you don’t want to. If you choose not to participate or stop participating, there are no penalties.
Will you be recording the discussion today?
Yes. With your permission, we plan to record the interview, only to make sure we are collecting everything you say. The recordings will remain AIR property and will be destroyed no later than one year after the end of the project.
How will you protect my privacy?
We will not use your name or the name of your nursing home in connection with anything you say, and we will not give your name to anyone outside of the project team. In addition, we will ensure that no statements may identify which nursing home is being described.
What if I want more information?
Please ask us today if you have any questions.
If you have additional questions or concerns about this research study, please contact the director of the research project at AIR, Elizabeth Frentzel, MPH, [email protected], (781) 373-7079, 201 Jones Road, Waltham, MA 02451
If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected] toll free at 1-800-634-0797 or c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
Please sign below if you agree to participate
Your signature:_______________________________ Today’s date:______________________
G-
| File Type | application/msword |
| Author | Elizabeth Frentzel |
| Last Modified By | Frentzel |
| File Modified | 2014-01-23 |
| File Created | 2014-01-23 |