CMS-10477 Focus group consent form

Attachment 4.e. Focus Group Consent Form (English)

CONSENT FORM

Introduction

We are asking you that you talk with us in a focus group. You need to read this consent form before you decide if you want to talk with us.

This consent form tells you:

• what the focus group is about,

• what we will ask focus group members to do,

• who can do the focus group,

• the risks and benefits of doing the focus group,

• how we will protect your information, and

• who you can call if you have questions.

Please ask the person who gave you this form to explain anything you don’t understand before you make your decision.

What is the purpose of the study?

The purpose of this focus group is talk with you about <Insert Program Name>. We want to learn about your likes and dislikes with <Insert Program Name>. You are one of about 360 people that we are talking with about programs in the United States.

RTI International is leading this focus group. RTI is a nonprofit research organization. The Centers for Medicare & Medicaid Services (CMS) is paying for this focus group. CMS is the federal agency that runs Medicare and helps pay for Medicaid and the Children’s Health Insurance Program. .

What will happen today?

If you agree to talk with us about <Insert Program Name>, the leader will ask you and other people in the group questions about what you liked and disliked about the program’s access, quality, and rewards or incentives.

An RTI researcher will lead the group discussion. We will audio-tape the focus groups and take notes. We may share the audio-tapes or notes with the project staff at CMS to see if they have any questions.

How long will this last?

The focus group will take about 90 minutes.

What are the risks of participating?

There are no known health risks for doing the focus group. However, it is possible that some of the questions in the focus group may make you upset. You can refuse to answer any question and you can take a break at any time during the focus group.

Although we have policies to ensure that your information is kept private, there is still a small risk that your privacy could be broken. 

What are the benefits?

Your benefits: You have no direct benefits for doing the focus group.

Benefits to others: We hope that the focus groups will help CMS understand likes and dislikes of the program. We also hope they will improve the overall quality of the program.

Will I be given anything?

You will get $75 for your time and effort and for any travel expenses you may have had to do the focus group.

How will my privacy be protected?

We will take many steps to protect your information. We will keep your personal information, the audio-tape, and the notes from the focus group under lock and key. We will not include your personal information, like your name, address, or telephone number, in our interview notes. We will not include your personal information in any future reports. We will report the findings from the focus groups in summary form. We will not identify you by name. We will keep a copy of the audio files on password-protected computers that only RTI team members have access to. We will delete the audio files within a year of the project’s end. We will ask that you respect others’ privacy today. Please do not share what is said in the group once it is over.

Future contacts

RTI and CMS may contact you in the future to do a survey or another focus group for this project.

Your rights

Your decision to do this focus group is completely voluntary. You can choose not to do the focus group. You can choose to stop doing the focus group at any time. You can refuse to answer any question. If you decide to talk with us now, you can change your mind later.

Your questions

If you have questions about the interview, you can call the RTI project director, Thomas Hoerger, at 1‑800-334-8571, ext. 21746. Leave a message with your name and phone number. Someone will call you back as soon as possible. If you have questions about your rights as a participant, you may call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

YOU WILL BE GIVEN A COPY OF THIS FORM TO KEEP.

Your initials below show that you have read the information provided above and have gotten answers to your questions. Also, it says that you have freely decided to participate in this interview. By agreeing to do this focus group, you are not giving up any of your legal rights.

______________ __________________________

Date Initials of Participant

______________ _______________________________

Date Signature of Witness

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