Form 0920-1154 Consent Form Provider (Online Survey)

Form Approved

OMB No. 0920-1154

Exp. Date: 1/31/2020

CONSENT FORM FOR

PARTICIPATION IN RESEARCH:

“Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy”

American Institutes for Research/Eureka Facts

You are being invited to participate in a research study on behalf of the Centers for Disease Control and Prevention (CDC), to inform them about clinicians’ knowledge, attitudes, and behavior pertinent to alcohol screening and brief intervention with women of reproductive age and women who are pregnant. This study is being conducted by American Institutes for Research (AIR) in collaboration with EurekaFacts, LLC.

Thank you for your interest in this survey.  If you agree to take part in this study, you will be asked to complete this consent form and the online survey.  The online survey will take you approximately 10-15 minutes to complete. You will receive an incentive of $10 (or equivalence in points) as a token of appreciation for your participation from the panel provider, Dynata, for your participation. 

There are no known risks to participating in this study. No more than minimal risk is expected during any phase of this study. Some individuals might experience discomfort when talking about sensitive topics like alcohol use, contraception (birth control), and pregnancy. All information obtained from the interview will remain strictly confidential.

You may not directly benefit from this research; however, we hope that your participation in the study may help CDC assess its outreach efforts to healthcare providers and improve patient communication materials about this important topic as well as to understand any other informational needs healthcare providers may have.

Your answers in this study will remain private.  By agreeing to participate in this survey, you are allowing CDC to use the information from this study. The information collected is for research only, and your name will not be shared with anyone outside of this study. The only instance when we would release information about you to anyone outside the project would be if we were required to do so by law, such as a subpoena or if we learned someone were in danger of harm. Any results that come from this study will be presented as an aggregate and your name will not be linked to your answers.

Your participation in this study is completely voluntary and you can stop at any time.  You are free to skip any question that you choose. There will not be any penalties if you refuse to participate in this study or refuse to answer any questions. 

This survey has been approved by AIR’s IRB. If you have any questions, please contact Dr. Hanno Petras (Project Director) at [email protected] or at 202-403-5639 or Erin Morrison Wallace (IRB Chair) at [email protected] or at 202-403-5542.

By clicking “I agree” below, you are indicating that you are at least 18 years old, have read and understood this consent form, and agree to participate in this research study.  

Healthcare Provider Online Survey Consent Form

Public reporting burden of this collection information is estimated to average 3 minutes, including 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 CDC/ ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333: ATTN: PRA (0920-1154).

The information you are being asked to provide is authorized to be collected under the System of Records Notices 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems. The principal purpose for which CDC will use the information that you provide is inform the development of patient and healthcare provider messages and materials about alcohol use during pregnancy. The information you provide will be included in a Privacy Act system of records, and will be used and may be disclosed for the purposes and routine uses described and published in the following System of Records Notice (SORN): 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems, [Federal Register: December 31, 1992 (Volume 57, Number 252)] [Notices] [Page 62812-62813]