Consent Form_PRA 2.8.22

Assessment of a Pharmacist-Led Transitions of Care Service Utilizing an Admissions Enhanced Patient Risk Evaluation Approach: the ICARE Program

OMB Control Number: 0910-0847

Expiration Date: 12/31/2022

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this voluntary information collection is 0910-0847. The burden time required to complete this portion of the information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information.

Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected]. DO NOT SEND YOUR COMPLETED FORM TO THIS PRA STAFF EMAIL ADDRESS.

CLINICAL health services

INFORMATION LETTER for a research study entitled

“Evaluation of provider perceptions of a pharmacist-led interprofessional transitions of

care program”

SPONSOR: This study is sponsored and funded by the U.S. Food and Drug Administration’s Center for Drug Evaluation and Research Safe Use Initiative.

You are invited to participate in a research study to learn about the impact of a pharmacist-led,

transitions of care (TOC) program. This study is being conducted by Dr. Courtney Gamston in the

Auburn Department of Clinical Affairs and Outreach. You are invited to participate because you

are a provider at East Alabama Medical Center (EAMC) and are age 19 or older.

What will be involved if you participate? If you decide to participate, you will be asked to

complete an anonymous survey related to TOC services at EAMC. The total amount of time to participate in the studies is approximately 15 minutes.

Are there any risks or discomforts? The only risk is related to the potential loss of

confidentiality. To minimize these risks, the survey will be anonymous and no identifiable

information will be collected.

Are there any benefits to yourself or others? If you participate in this study, your survey answers

could potentially be used to improve the transitions of care services offered at EAMC.

Will you receive compensation for participating? There is no compensation for participating.

Are there any costs? There are no costs to participate.

If you change your mind about participating, you can withdraw by not completing the survey

or exiting out of the browser window, as applicable. Your decision about whether or not to

participate or to stop participating will not jeopardize your future relations with Auburn University

or EAMC.

Any data obtained in connection with this study will remain anonymous. We will protect your

privacy and the data you provide by administering and anonymous survey. Information collected

through your participation may be presented at local, regional, or national conferences or submitted

for publication.

If you have questions about this study, you can contact study investigator Dr. Courtney

Gamston, Professor of Experiential Practice at Auburn University at 334-844-4099 or

[email protected]. For questions about your rights as a research subject, you can contact the

Chairperson of the EAMC IRB at 334-528-1326.

HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE IF YOU WANT

TO PARTICIPATE IN THIS RESEARCH PROJECT. IF YOU DECIDE TO PARTICIPATE,

THE DATA YOU PROVIDE WILL SERVE AS YOUR AGREEMENT TO DO SO.