ATTACHMENT 6:
Living with Lung Cancer Study
Contact Information Form
and
Consent for Contact
Form Approved
OMB No. 0920-xxxx
Exp. xx/xx/xxxx
“Living with Lung Cancer Study”
contact information Form
INSTRUCTIONS TO CLINIC STAFF:
Please send this form to the RTI Study Coordinator for follow-up.
NAME
HOME PHONE NUMBER ( )
WORK PHONE NUMBER ( )
CELL PHONE NUMBER ( )
E-MAIL OR OTHER CONTACT INFO
Would it be okay for us to leave a message on your phone?
Home: Y/N Work: Y/N Cell: Y/N
Public reporting burden of
this collection of information is estimated to average 8 minutes per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
Living with Lung Cancer Study
Consent for Contact
Your health care provider is working with the Centers for Disease Control and Prevention (CDC) and RTI International to conduct interviews with people living with lung cancer. These interviews are part of a study to learn more about the experience and needs of people living with lung cancer.
As someone identified as having been diagnosed with lung cancer over 6 months ago and between the ages of 30 and 80, we would like to talk to you about your experiences and any challenges you have faced in living with lung cancer. We will be completing a total of 27 interviews with people living with lung cancer.
If you are interested in participating in this study, your health care provider would need to share your contact information with a representative of RTI International, a nonprofit research organization, so they can talk to you further about participation. If you agree to be contacted, you are only saying you would like additional information. If you choose to participate in the study, you will be asked to provide a separate consent agreement. At any point, you may refuse to participate any further.
By signing this form, I agree to let someone contact me to learn more about this study. Upon learning more about the study, I will agree or refuse to participate in the study at that time.
NAME
(print)
Signature ___________________________ Date _____________________________
File Type | application/msword |
File Title | Form Approved |
Author | Peyton Williams |
Last Modified By | arp5 |
File Modified | 2008-12-23 |
File Created | 2008-12-18 |