Form 1 Listening Session Consent Form revised July 6

CONSENT FORM – Listening Session

What is the purpose of this listening session?

John Snow, Inc. (JSI), an independent public health firm, has been contracted by HRSA (Health Resources and Services Administration) to develop an employee well-being, burnout, and job satisfaction survey for use in Federally Qualified Health Centers (FQHC’s). The purpose of this listening session is to gather information regarding which factors affect employee feelings of job satisfaction or dissatisfaction, factors that lead to burnout and well-being, and anything else that influences how employees feel about working at health centers. The information that we gather will help us to build a more valid survey that will provide useful information for health center administrators and HRSA to try to improve working conditions. If you agree to participate in the listening session, it should take approximately 90-120 minutes of your time.

How will my responses be used?

Your responses in the session will help JSI and HRSA develop a Health Center Workforce Survey that will assess the causes, effects, and extent of employee burnout, well-being, and job satisfaction. Ultimately when Health Centers use this survey in the future, it will provide Centers with a reading on their employees’ status on these issues and also help to gauge progress in addressing any of these problems.

We strive to keep the information you tell us in the listening session as confidential as possible by asking all participating listening session members to only use your first name, not to mention your health center’s name, or any other distinctive characteristics. Listening sessions are like a focus group meaning that you will be participating alongside other health center workers. Your fellow participants have been recruited from across the country in a variety of types and locations of health centers. Each Listening Session will have between 10-12 participants from similar occupations as your own. No two participants will come from the same health center. We ask that all of you pledge to keep anything you hear in the session confidential and to not repeat anything you hear outside of this session.

Individual answers will not be available to any persons outside of the JSI project staff. JSI will protect your privacy by not reporting results in ways that could directly identify participants. Instead we will only report on themes and summaries of answers participants give.

What is the risk of taking part in the listening session?

There are few risks. You will be asked questions about your opinions and experiences regarding your workplace. If any of these questions make you feel uncomfortable, you can choose not to answer. In a focus group setting, other participating health center employees will hear your responses, and you will be able to hear theirs. While unlikely, it is possible that you or other health center employees will mention information that makes them or their health centers distinguishable. We ask listening session participants to avoid repeating what was heard in the interview. JSI will keep all answers private to prevent any risk to your relationship with your employer or your coworkers.

What are the benefits of taking part in the listening session?

The answers you give today will help JSI and HRSA better understand the causes, impact and extent of burnout, well-being, and job satisfaction for health center employees, patient care, and communities. This information will help us to build a more valid Health Center Workforce Survey to be used by Health Centers across the country. As a token of appreciation for your participation, you will be sent a $100 gift card.

Who should I call if I have questions?

This project is directed by Thomas Mangione, PhD at JSI. You may call him at (617) 482-9485 if you have questions about this activity. If you have questions about your rights as a participant or if you feel you have been harmed, call Laurie Kunches, PhD, Chair of the JSI Institutional Review Board at (617) 482-9485.

Can I refuse to be part of the session?

Participation in the session is up to you. Your decision to participate or not has no effect on your employment. Also, you can decide not to answer any question during the session as you choose. However, by participating and sharing your opinions/experiences, you will help us to build a more valid survey.

OMB Approval for this government sponsored activity

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. The OMB control number for this project is: 0915-0379. Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, signing informed consent, and participating in the listening session. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

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Health Center Workforce Well-Being Survey

Listening Session Informed Consent

John Snow, Inc.