3 Attachment D – Participant Consent Form

Attachment D – Participant Consent Form

CONSENT FORM

Agency for Healthcare Research and Quality (AHRQ), its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. The Privacy Act notice on the back of this form describes the conditions under which information related to this study will be used by AHRQ employees and agents.

The purpose of this research is to help AHRQ better understand whether individuals can provide key pieces of health insurance benefits and coverage information and understand the level of effort necessary to provide this information.

During this research, you may be audio and/or videotaped, or you may be observed. If you do not wish to be taped, you still may participate in this research.

During this research, the researchers will make digital copies of the documents about your insurance coverage that you have provided. These copies are for research purposes only; they will be stored securely and will not be shared with any individuals outside the research team. These copies will not be included in any reporting on the findings from this research, and will be discarded upon completion of the study.

We estimate that participating in this [interview/focus group] will take an average of 60 minutes (ranging from 40 minutes to 80 minutes). We anticipate you’ll need an additional 30 minutes to gather materials in preparation for the [interview/focus group].

Your participation in this research project is voluntary, and you have the right to stop at any time.

While participating, you will not be asked to answer any specific questions about your own or your family members’ health status, health conditions, or insurance claims. The research team cannot provide any guidance, answers, or advice on these types of issues.

The research does not involve any foreseeable risks. There are no direct benefits to participants in the research.

If you have questions about this research or your rights as a participant in this study please contact Project Director at (240) 333-4814.

If you agree to participate, please sign below.

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. OMB control number is ####, and expires ####.

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I have read and understand the statements above. I consent to participate in this study.

___________________________________ ___________________________

Participant's signature Date

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Participant's printed name

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Researcher's signature

OMB Control Number:

Expiration Date:

PRIVACY ACT STATEMENT

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that this study is sponsored by Agency for Healthcare Research and Quality (AHRQ). Your voluntary participation is important to the success of this study and will enable AHRQ to better understand the behavioral and psychological processes of individuals, as they reflect on the accuracy of AHRQ information collections. AHRQ, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent.