Consent form

Appendix G: Informed Consent Form

Evaluation of HHS Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care in Health and Health Care Organizations

INFORMED CONSENT FORM

PURPOSE
The Office of Minority Health (OMH) at the Department of Health and Human Services (HHS) is working to understand how its National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, or the National CLAS Standards, National CLAS Standards, are understood, adopted, and implemented in health and health care organizations across the country. As part of this assessment project, we are conducting key informant interviews and surveys with health and health care professionals throughout the country. The key informant interview will take approximately 1-1 1/2 hours. The survey will take approximately 30 minutes.

RISKS
There are no foreseeable risks for participating in this research.

BENEFITS
While there are no direct benefits to you, by taking part in this project, you have the opportunity to help the HHS Office of Minority Health understand better how health and health care professionals and organizations become aware of, gain knowledge about, adopt, and implement the National CLAS Standards.

CONFIDENTIALITY
The data in this study will be confidential. Everything you tell us will remain anonymous. We will not use your name or other identifying information in any materials that result from this project.

For the interviews, audio-taping will include a description of time of taping and information sought from tapes. Recordings will be kept secure and password-protected in a locked file in the principal investigator’s office and will be destroyed after seven (7) years.

For the survey, names and other personally identified information will not be placed on surveys or other research data. For coded identifiable data (such as sex, race, ethnicity, name of organization), participant’s individual names will not be included on surveys. A unique code will be placed on the survey, and kept separately and secured from the survey responses, which only the investigators will use to link survey responses to participant identity through the use of an identification key.

PARTICIPATION
Your participation is voluntary, and you may withdraw from the assessment project at any time and for any reason. If you decide not to participate or if you withdraw from the project, there is no penalty or loss of benefits to which you are otherwise entitled. There are no costs to you or any other party.

CONTACT
This assessment project is being conducted by the Health Determinants & Disparities Practice at SRA International, Inc. and Rodney Hopson, College of Education and Human Development, Division of Educational Psychology, Research Methods, Education Policy at George Mason University. Staff in the Health Determinants & Disparities Practice at SRA International may be reached at 240.514.2991 for questions or to report an assessment project-related problem. You may contact the George Mason University Office of Research Integrity & Assurance at 703-993-4121 if you have questions or comments regarding your rights as a participant in this project.

This research has been reviewed according to George Mason University procedures governing your participation in this research.

CONSENT
I have read and understand the information regarding my participation in this interview about the HHS OMH’s National CLAS Standards, all of my questions have been answered by the research staff, and I agree to participate in this study.

____________ I also agree to audio taping.

____________ I also do not agree to audio taping.

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Name
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Date of Signature