Appendix B Interview Consent

OMB Number: 0925-0653 Expiration Date: 04/30/2018

Appendix B: Consent Form

National Institute of Nursing Research (NINR)

Pediatric Palliative Care Materials Review Interview

I understand that my participation in this interview is voluntary. I understand the purpose of this interview. If, at any time, I wish to stop the interview, I may do so without giving an explanation.

I am aware that the interviewer will not identify me by name in any reports using information obtained from this interview, and that my privacy as a participant will be protected to the extent permitted by law.

I understand that I will receive a $40.00 gift card in appreciation for my participation, and that if I withdraw from the interview, I will not receive this compensation.

I have been given a copy of this consent form that I may keep for my own reference. In-person interviews only; will not be read aloud for audio consent. Alt: I understand that I may request a copy of this consent statement.

I certify that I am at least 18 years of age. I have read the above form and I consent to take part in today's interview. In addition to agreeing to participate, I consent to having the interview tape-recorded.

Signature ____________________________________________ Date ____________________

Name (printed) ____________________________________________________________

Interviewer Signature __________________________________ Date ____________________