Post-Clinic Visit Survey_Consent Statement_English

ATTACHMENT 10e

Post-Clinic Visit Survey:

Consent Statement, English

You are being asked to participate in this study because you receive care at [CLINIC] and are eligible for prostate cancer screening. The purpose of this survey is to gather information about your prostate cancer screening history and decision making. If you complete this survey, you will receive a $25 gift card.

Who is sending this survey? ICF is a consulting firm that is working with the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) to evaluate different prostate cancer screening decision aids and their ability to help men aged 55-69 years make a decision whether to get a prostate-specific antigen (PSA) test. A PSA test is a blood test that measures the level of PSA in the blood. PSA is a substance made by the prostate.

How long will it take? This survey will take no longer than 20 minutes. Your participation in this study is 100% voluntary which means you can choose whether or not you want to take part in this study.

What are the risks and benefits of doing the survey? As a participant in our study, there is a minimal risk related to your privacy and/or confidentiality, but steps have been taken to remove your personal information so that you cannot be identified. Only members of the research team will have access to study information. Remember, you are free to choose not to participate in this study. You are also free to leave the study at any time. Leaving the study will not interfere with your care, payment for your health care, or your eligibility for health care benefits.

Is there a cost associated with the study? There are no costs to you for participating in this study.

What will happen next? The study team may contact you by text, email, or phone to share information or invite you to respond to other surveys or interviews. All requests for information are voluntary. The purpose and topic of each request for information will be shared with you so you can choose whether you want to participate. Your choice to participate or not participate in future requests will not interfere with your care at the clinic.

How will my information be shared outside of the study?  Your personal responses will not be shared outside of the study. Summaries of survey results that are not linked to your name will be shared with CDC and/or may be published in a professional journal.  

Who do I call about problems or questions? If you have questions about or concerns about your participation in this project, please contact the ICF project manager – Danielle Nielsen at [email protected]. For questions regarding your rights as a study participant, you can contact ICF’s Institutional Review Board (IRB) representative Christine Walrath at (646) 695-8154 or [email protected].

If you agree to participate in this study, please click “Begin Survey.”

If you do not agree to participate, please click, “I decline.”

01 Begin survey

02 I decline