Clinic Coordinator Interviews_Consent Statement

ATTACHMENT 11a

Clinic Coordinator Interviews:

Consent Statement, English

My name is [ICF staff member’s name] and I work for a company called ICF. 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 decide whether to get a PSA test.

The purpose of this interview is to understand the challenges and best practices for incorporating a human simulation decision aid called Talk to Nathan About Prostate Cancer Screening into the clinical workflow of primary care. Talk to Nathan About Prostate Cancer Screening is DCPC’s online, interactive human simulation decision aid designed to help men learn and make informed decisions about prostate cancer screening. This information, along with the data collected via patient and provider surveys, will help us answer our research questions and meet study objectives to determine the effectiveness of the interactive decision aid versus a standard decision aid or education materials in helping men decide on whether to get screened for prostate cancer.

The interview should take about 30 minutes. There are no right or wrong answers. We are just looking for your honest opinions and perceptions.

Your participation in this conversation is completely voluntary. You do not have to answer any question you don’t feel comfortable answering and you may choose not to participate or to leave the discussion at any time without penalty.

As a participant in our study, there is minimal risk related to your privacy/confidentiality. However, we will not associate your name with the information that you share for the purpose of this project. We will not share any identifying information in any reports or presentations that include findings from these interviews. Only members of the research team will have access to study information.

If you have questions about or concerns about your participation in this interview or 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].

Do you agree to participate?

• Yes 

• No

With your permission, we would like to audio record the interview. The audio recording will be professionally transcribed to aid in summarizing the findings from the project. Even if you decide to turn or keep your camera on during this discussion, we will only be recording the audio from our conversation today. Do you agree to be audio recorded?

• Yes 

• No