CMS-10467 Verbal Consent Statement

EVALUATION OF THE GRADUATE NURSE EDUCATION DEMONSTRATION PROGRAM

OMB No. 0938-1212

Expires 9/30/2016

Attachment 2: Verbal Consent Statement

Contract No. HHSM-500-2011-00013I

Task Order No. HHSM-500-T0009

07/06/2015

The following verbal consent statements will be read prior to each GNE Oversight and SON Administrative Team check-in calls and post-Demonstration interviews:

“The purpose of this interview is to discuss your ongoing activities related to the GNE

Demonstration Project, including changes, challenges, successful strategies, perceived outcomes, and sustainability plans.

Your participation in this interview is voluntary. If, at any time, you wish to discontinue participation, you may do so without penalty.

The interview will last about 60 minutes and with your permission will be audio-recorded for our records. Only IMPAQ staff will have access to the recordings and they will be destroyed upon completion of the evaluation.

This interview will work best if you do most of the talking. Feel free to speak openly and candidly about your experiences and perspectives regarding this demonstration.

We will treat the information you supply in a confidential manner. Only selected staff from the evaluation team will have access to your actual interview responses. You will not be identified by name in any report to the public or the funder, but we may refer to you by title, e.g., “Dean, School of Nursing,” “Chief Nursing Officer.”

As part of the evaluation, we will share our findings with CMS. The results of the evaluation will describe strengths as well as areas for improvement. Findings will describe the progress made and difficulties encountered in achieving project goals. Although you will not be identified by name, it is likely that readers will be able to identify specific GNE projects and may also be able to identify participating individuals based on their role within the project.

After the interview is completed, we will ask you to identify any information which you would NOT want presented in any form that might be linked with your personally or with your GNE project. We will comply with your request by being especially careful to not present such information in any way that would enable it to be linked to you or your GNE demonstration project.

[Ask all participants] Do you agree to participate in this interview? [Yes No]

• [If no]: Can you share some of the reasons why you are declining? Thank you for your time.

• [If yes]: Do we have your permission to audio-record this interview? [Yes No]”