0920-0978 FluSurv NET Consent From English

Form approved OMB 0920-0978

Influenza Hospitalization Surveillance Project Consent Form (for patient/proxy interview ONLY)
VERBAL CONSENT FORM
Hello. My name is _____________ from the [state] Department of Public Health. May I speak to [patient’s name /parent of
(child’s name)]? We are working with the Centers for Disease Control and Prevention and other health departments to learn
more about influenza disease or the flu. To do this, we are talking to people who have been in the hospital with flu. We want
to look at things that may affect their illness and whether they were vaccinated against flu.
Because you/your child [or NAME if speaking with proxy] were in the hospital for the flu beginning on [day admitted], I
would like to ask you a few questions about whether you/your child [or NAME if speaking with proxy] received the flu
vaccine this season. This will take about five minutes. Your participation is voluntary and if you choose to refuse it will not
affect any medical care or benefits you receive. All of your responses will be kept confidential as much as the law allows.
You may refuse to answer any questions and may stop at any time. This information will help [State/Local Health
Department] and CDC better describe influenza-associated hospitalizations. Additionally, this information may help us
improve vaccination recommendations for flu and better protect the public’s health. There is no other benefit to you for
answering these questions. There is also no risk to you. If you have any questions about the study, you may call [state
contact] at the Department of Public Health at XXX-XXX-XXXX. Do you have any questions before I begin?
May I continue with this interview? □ Yes

□ No [If YES, go to Appendix F]

If NO: Thank you for your time. Have a good day.
Name of person obtaining verbal consent: _____________________

Date: ______________________________

Flesch-Kincaid: 7.7

Influenza Hospitalization Surveillance Project Case and Proxy Identifying Information

Patient Last name: ______________________________First name: ___________________ Initial: ______________
Date of birth: ______ /______ /________

Phone Number: _____________________________________________

Proxy Last name: _______________________________ First name: ___________________ Initial: _____________
Phone Number: _________________________________ Relationship to case patient _________________________

Note to collaborators: This is for your records only. Do not send this information to CDC. Keep this
information in a secure locked place.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).