Attachment 1-D. Study 1 Consent form

The Purpose of This Research

You are being asked to participate in in a three-part study over three months about health events to help improve the Medical Expenditure Panel Survey (MEPS), which is conducted by the Agency for Healthcare Research and Quality (AHRQ) in the U.S. Department of Health and Human Services. MEPS is an on-going, nationwide survey that studies the cost of health care and the way Americans pay for that health care.

How To Participate

The study consists of three interviews, with about three weeks between each. All interviews will take place over Zoom – the first two interviews will each be 30 minutes, and the final interview will be 90 minutes. In the first two interviews, an interviewer will observe you as you fill out a short web survey about your household’s health care usage. The interviewer will ask you to share feedback on the questions.

In the final interview, the interviewer will ask you a longer set of health questions over Zoom.

As tokens of appreciation for your time, for the first two interviews, you will be sent a $25 electronic gift card after each completed interview. For the last interview, you will be sent a $75 electronic gift card.

You are encouraged to have notes or records of your family’s health care events available for each interview.

Permission to Record

We would like to ask for your permission to audio and video record the Zoom interviews. If the recordings are reviewed later, they will only be by a few Westat staff and possibly the client (AHRQ).

Protecting the Confidentiality of the Information You Provide

To help keep everything private:

• Your name will not be recorded on the interview notes or reported in any reports.

• Everything that you say will be confidential – that is, no one outside the research team will know what you told us.

• The things you say may be put in a written summary of this interview. Your name will not be linked to any of your responses, though we may include quotes that you provide in our reports.

Participation is Voluntary

Participation in each part of the study is voluntary. You have the right to stop at any time or to refuse to answer any question There is no penalty or loss of benefits if you choose not to participate in any part of the study.

Benefits and Risks of This Research

Your participation in this study will help us to evaluate ways to improve the collection of health care event data. There are no known risks to participation.

To Learn More About MEPS

To learn more about this study,

contact Alex Scott, a study representative at

1-800-945-MEPS (6377). If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your first name, the name of the research study that you are calling about (the MEPS Test), and a phone number beginning with the area code. Someone will return your call as soon as possible.

Attachment 1D: Study 1 Informed Consent 1D-2