0920-20PT Consent Form_Physician

Consent Form for Participation in a Physician Interview

You have been asked to take part in an interview that is being conducted by KRC Research and GC Global Research for the Centers for Disease Control and Prevention (CDC). Your participation in this activity is voluntary. If you agree to participate, we ask you to read and sign this consent form. You may withdraw your consent to participate, for any reason, at any time.

Details about this study are discussed in the following sections. It is important that you make an informed choice about participating. You should ask the study staff any questions you have at any time.

Key Information

• Your consent is being sought to participate in a study.

• Participation is voluntary.

• The aim of the study is to learn about physician practices and thinking related to a health topic.

• You will participate in a virtual interview that will last about 60 minutes.

• The interview will be video and audio recorded for accuracy in reporting.

• If any questions make you feel uncomfortable, you may choose not to answer.

• There is no direct benefit to you for participating in this study.

• The results may help CDC learn more about the practices of physicians

to help inform CDC’s educational and outreach efforts.

• The alternative to participating in this study is to not participate.

Purpose

These virtual interviews are being conducted by KRC Research on behalf of the CDC to learn about physician practices and thinking about a health topic. You will be asked about your screening opinions and practices. You do not need to disclose any information that you do not want to share. Qualifying physicians are being asked to participate in these interviews because their feedback will help inform the CDC’s educational and outreach efforts.

Procedures

The interview will take place virtually, using your computer and phone. This one-time interview will last one hour (60 minutes). The conversation will be in English. During the interview we will address you with a first name that you provide to the interviewer. We will not use your full name.

The session will be video and audio recorded. Only project staff from KRC Research and CDC will have access to these recordings. They will be used to create a written transcript. There will be no information in the transcript to identify you personally. The transcript will only be used for writing an accurate report. You must consent to the video and audio recordings, transcript, and note taking to participate.

Project staff from KRC Research and CDC may listen in on the interview and take notes. They will not be joining the discussion, and they will not identify you by name in their notes. There will be no casual observers or persons unrelated to the project listening to the interview.

Anticipated Benefits and Potential Risks

There are no foreseeable risks to participating in this study. However, if any questions make you uncomfortable, you may choose not to provide an answer. There is a chance that confidentiality of the information you share could be breached, but we will take steps to minimize this risk, as discussed below.

There is no direct benefit to you for participating. However, the study is expected to help CDC learn more about the practices and preferences of physicians to help inform CDC’s educational and outreach efforts.

Costs and Payment for Participation

There is no cost to you to participate in this study except for the time you spend participating in the interview. You will be paid a $75 as a token of appreciation for your participation.

Privacy and Confidentiality

The video and audio recordings and any written notes made by the interviewer or project staff will be used for analysis and reporting only. The recordings and transcript will be stored securely at KRC Research and made accessible only to authorized staff at KRC Research, the managerial staff of the CDC team, and transcribers. The recordings and transcript will not be made public or used for any advertising or commercial purposes. Identities of participants will not be included in the transcript.

KRC Research will report summarized results from all interviews with physicians, with excerpts (quotes) from individuals not identified by name, so your identity will not be known to report readers. We will not disclose any information that can be used to identify you, or connect your name to information presented in reports or papers. The audio and video recordings will be destroyed after the transcript has been completed and the project report approved by the CDC.

In most cases, only the CDC and staff involved in this project will have access to the records, the interview video and audio recordings, and the transcript with what participants in the group said. Although rare, regulatory authorities have authority to view records if necessary.

Participation and Withdrawal

You are free to withdraw from or leave the study at any time, for any reason. If you decide not to take part, there will be no penalty or loss of benefits to which you are otherwise entitled. If you do not take part in the interview, you will not receive the $75 token of appreciation.

Identification of Investigators

If you have any questions or concerns about this activity, you may call ____________ at (XXX) XXX-XXXX or send a message to INSERT EMAIL.

If you would like to speak to someone other than the study staff about your rights as a participant, you can contact INSERT at CDC at INSERT EMAIL. Reference TB study.

________________________________________________________________

I have read all of the information about my involvement in the study and agree to participate in this interview which will be audio/video recorded.

________________________________________

Print Name

________________________________________ _____________________________

Signature Date

Please email [email address] or fax [fax number] your signed consent form to [name], the study coordinator. If you need assistance, please call [phone number and extension]. Please keep a copy of this form for your records.

May 1, 2020 Page 3 of 3