Asynchronous Focus Group Consent-Clinicians and Healthcare Professionals

Form Approved

OMB No. 0955-XXXX

Exp. Date TBD

Access, Exchange, and Use of Social Determinants of Health Data in Clinical Notes (SDOH)

Asynchronous Clinicians and Healthcare Professionals Focus Group:

Prospective Agreement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0955-XXXX. The time required to complete this information collection is estimated to average 90 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

MEDPANEL ASYNCHRONOUS (NOT LIVE) ONLINE FOCUS GROUP

(Clinicians/Healthcare Professionals)

PARTICIPANT AGREEMENT AND CONSENT

MedPanel, Inc. wishes to invite you to participate in an online clinician/healthcare professional focus group on <Topic X>, scheduled between <Date X> and <Date Y>, 2021. The focus group is not live and is held using a self-paced digital message board format. The focus group will be open for response between <Time X> and <Time Y> daily in <participant’s own time zone>. It is estimated that you would spend up to 90 minutes to complete all activities.

MedPanel is conducting these focus groups on behalf of the Office of the National Coordinator for Health Information Technology and researchers at Harvard Medical School. All information about you will be kept strictly confidential.

The following is an overview of the focus group activities, should you choose to participate in the focus group:

Online Focus Group Participation: This focus group will be held using Focus Vision, an online focus group platform.You will be able to log-in to Focus Vision between <Date X> and <Date Y> during the hours of <Time X> to <Time Y> <Participant’s time zone> every day to answer pre-set questions, see other participants’ responses to the same questions, and respond to probes by the MedPanel moderator. Other participants, like yourself, will be anonymous. A MedPanel moderator will be monitoring the online platform to see whether you have answered all the requisite questions, which may be geared toward obtaining:

• Your experience as a clinician/healthcare professional

• Your feedback on social determinants of health and their documentation in the medical record

• Your feedback on your experience with answering the questions online

You may stop participating in the focus group at any time.

Researcher Engagement with the Focus Group: Between <Date X> and <Date Y>), the research team at Harvard Medical School will be observing focus group interactions and will read participant feedback. However, researchers will not be able to interact with you directly. During the discussion, researchers may send questions via “chat” to the MedPanel moderator if they would like additional information or clarity. To maintain your confidentiality, please limit use of additional personal identifiers during the meeting such as your last name or where you live.

Transcription of Focus Group Content: The focus group and its participants’ written contributions will be transcribed for the research team’s internal use, such as clinical research, training, reports and presentations (“Transcript”). By agreeing to participate in the focus group, you understand and consent that:

-The Transcript may now or in the future be used for appropriate internal presentation and you waive any right to inspect or approve.

-MedPanel or the research team may distribute the Transcript solely for the internal uses described above.

-The Transcript may be retained by MedPanel and the research team, for a period of 3 years on a secure server, and thus may be subject to continuing use and disclosure for the purposes described in this Consent.

At all times and in all uses, including in the Transcript, your identity will remain confidential to MedPanel and will not be made known to the research team.

Should you participate, MedPanel will collect the following personal information and hold it confidentially:

• Full Name (not sent or shared with the research team; it is collected by MedPanel Inc. to record your participation)

• Email Address – Also not sent or shared with the research team

• Year of birth

• Race/Ethnicity (optional)

Your participation in this focus group is voluntary. If you have questions about your rights as a research participant or would like to speak with someone independent from the research team, please contact the Human Subject Protection Office (617) 975-8500.

Please indicate which applies to you:

□ I agree to the terms of this ASYNCHRONOUS ONLINE FOCUS GROUP PARTICIPANT AGREEMENT AND CONSENT.

□ I do not agree to the terms of this ASYNCHRONOUS ONLINE FOCUS GROUP PARTICIPANT AGREEMENT AND CONSENT. (Note: this will disqualify you from participating.)

Thank you for your cooperation.

PARTICIPANT:

________________________________________________

Signature

________________________________________________

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