CMS-10623 Consent Form

Testing Experience and Functional Tools Demonstration:

Personal Health Record User Survey Instrument Consent Form

Testing Experience and Functional Tools Demonstration: Personal Health Record (PHR) User Survey

Paperwork Reduction Act Submission

Appendix C:
Personal Health Record Survey Consent Form

CMS-10623

OMB Control Number: 0938-New

Consent Form

TEFT PHR User Survey

Instructions:

• The following page is a template for the consent form.

• Text that may need modification to tailor it to the situation is indicated in brackets.

Consent Form

TEFT PHR User Survey

We are asking you to complete a Personal Health Record (PHR) user survey.

You do not have to answer the PHR user survey.

If you say yes, you can quit at any time.

Your services and supports will not change in any way.

Why are you doing this survey?

This survey will ask you questions about an electronic tool that you were recently offered for your computer or phone called [Insert state-specific Personal Health Record name]. Using the tool, you can see information about the help you get. You may also use it to talk with the people who help you.

What happens if I say yes, I want to answer the questions?

If you say yes, you will:

• Fill out an online survey that asks you questions about your experiences with [Insert state-specific Personal Health Record name].

There are no right or wrong answers to these questions. It is okay if you ask for help with your answers from someone you trust.

How long will the survey take?

The survey will take about 15 minutes of your time.

What happens if I say no, I do not want to answer the survey?

No one will treat you differently. You will not be penalized. The services and supports you get will not change.

What happens if I say yes, but change my mind later?

You can stop answering the questions at any time. You will not be penalized. The services and supports you get will not change.

Who will see my answers?

Only the people who field this survey will see your answers. They will not know the answers are yours. This survey is anonymous, which means that your name is not connected to your answers.

Will it cost me anything to answer the questions?

No.

Will answering these questions help me in any way?

Answering the questions will not help you right now, but may help older adults and people with disabilities in the future.

Is there any way answering the questions could be bad for me?

No.

What if I have questions?

Please call the researchers at [INSERT NUMBER] if you have any questions about the study.

Do I have to give consent?

No. You only give your consent if you want to answer the questions.

What should I do if I want to be in the study?

You already have the online version of the survey. If you agree to complete it, select “agree” below. If you complete the survey, you are saying:

• You agree to be in the study.

You know that:

• You can stop answering questions at any time and nothing will happen to you.

• You can call [INSERT NAME AND NUMBER] at any time if you have questions.

ELECTRONIC CONSENT: Please select your choice below.

Clicking on the "agree" button below indicates that:

• you have read the above information

• you voluntarily agree to participate

• you are at least 18 years of age

If you do not wish to participate in the research study, please decline participation by clicking on the "disagree" button or closing the survey window.

☐ agree

☐ disagree

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