2 Attachment D Consent Form

Attachment D: Consent form

OMB No. 0925-0589

Expiration Date: July 17, 2017

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3). The purpose of this data collection is to confirm that the respondent understands their rights as a study participant. Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this project. The report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-09). Do not return the completed form to this address.

COGNITIVE TESTING CONSENT FORM

We would like to talk with you about a questionnaire Westat is developing as part of the Health Information National Trends Survey (HINTS). Westat is conducting this research for the U.S. Dept. of Health and Human Services (HHS). The questionnaire asks about health-related topics. By taking part in this interview, you are helping us evaluate how easy or difficult the questions are to understand and answer. Your opinions will help us improve the questionnaire.

• Your participation is completely voluntary. You may stop at any time, and you can skip any questions you do not wish to answer.

• All information obtained during this study will be treated as secure and will only be used to develop and improve the questionnaire. We will not share your answers with anyone outside of the HINTS project research team.

• The interviewer will audio record the discussion and take notes. In addition, project researchers may observe the interview. The researchers will destroy the audio recording as soon as they complete the questionnaire development process.

• The interview should take about an hour and a half.

• The report summarizing the findings will not contain any names or identifying information.

• You will receive $50 cash as a token of our appreciation for completing the session.

• If you have questions about this research, please contact Brad Hesse, the Principal Investigator at (240-276-6721; [email protected]). If you have questions about your role as a research participant, please contact Sharon Zack, the Westat Institutional Review Board Administrator (301-251-1500; [email protected]).

• A copy of this consent form has been provided for your records.

If you agree to participate in this interview, please sign the following statement.

I have read this consent form and understand the proposed project. I consent to participate in this study and to have the interview audio taped.

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Participant’s Signature Researcher’s Signature

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Printed Name Printed Name

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