Consent form

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Interview Consent Form

Thanks for taking the time to speak with us. Please read the information on the first page carefully. If you consent to be interviewed, fill out the second page. If you have any questions or would like a copy of this form for your records, email Malinee Shah at [email protected].
We'll use this interview for:
    • Making recommendations to The Centers for Medicare & Medicaid Services (CMS) on Caregivers’ data, technology and access needs
    • Internal presentations to members of the CMS Data & Analytics Strategy Group (DASG) team
Being interviewed is completely voluntary 
and up to you. 
    • You don't have to answer any questions that may be uncomfortable 
for any reason.
    • You can ask us to stop the interview at any time.
    • You can request that we don't use portions or any of your interviews, even after we are done.

We will keep your information secure.
    • We will never ask for private information like age, gender, or religious affiliation.
    • What you share will remain private within the research team. Only we have access to raw notes and video/audio recordings. 
    • We will never use your name or other personally identifiable information in summarized findings that are shared with the wider team. 
    • If we ever would like to publicly share a quote or recording from your interview, we'll always ask you first. If you say no, we will not share it.
Statement of consent
By answering the following, you agree to participate in CMS’ research 
into Caregivers’ data, technology and access needs 
I agree to let CMS:
    • Interview me
    • Take notes
    • Take photos
    • Audio record this session
    • Video record this session
We won't use what you share with us for any reason besides those listed above. 
Sign below to indicate that you have read this form and agree to be interviewed, recorded, and/or photographed as part of this research.

_______________________________________ 				
Printed name

_______________________________________ 				
Sign here

_______________________ 	
Date

Thank you! We appreciate your participation!

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1382. 

What is the goal?
This information collection is for understanding Medicare enrollees’ digital healthcare information needs and making recommendations to the Center for Medicaid and Medicare Services (CMS) for how to better serve Medicare enrollees’ needs. 

How long will it take?
The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. 

You can leave for any reason and your privacy is important.
This information collection is voluntary, and confidential. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.