Att 5._Consent Script for Survey

Att 5 Consent Script.docx

Chronic Q Fever in the United States: Enhanced Clinical Surveillance

Att 5._Consent Script for Survey

OMB: 0920-1305

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Dear Dr. [insert name],

Thank you for consulting with CDC’s Rickettsial Zoonoses Branch about the clinical care and management of a complicated chronic Q fever case. Q fever is a nationally notifiable disease; the current surveillance system collects minimal information on the clinical findings and risk factors for chronic Q fever. We have developed an enhanced clinical surveillance tool to gather more detailed and specific clinical data chronic Q fever to better understand its presentation, management, and long-term outcomes. This information will allow for better characterization of chronic Q fever in the United States.

Your participation in this survey is strictly voluntary and you may stop at any time. All information collected will remain anonymous; we will not collect any personally identifiable information for the patient, such as your patient’s name or contact information. We will collect contact information for the clinician responsible for care of the patient, but names of clinicians will not be collected. There are no negative consequences to you should you decline to participate or not complete the survey in its entirety. You may continue to consult with CDC’s Rickettsial Zoonoses Branch regardless of your participation in enhanced surveillance.

This survey should take you approximately 20 minutes to complete.

If you have any questions or concerns about completing this survey, please contact: 970-787-5036 or [email protected].

The Rickettsial Zoonoses Branch thanks you for your time and involvement.



Centers for Disease Control and Prevention

National Center for Emerging and Zoonotic Infectious Diseases

Division of Vector-Borne Diseases

Rickettsial Zoonoses Branch















File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCherry, Cara C. (CDC/DDID/NCEZID)
File Modified0000-00-00
File Created2023-09-27

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