Att 9 Informed Consent Form

ATTACHMENT 9:

INFORMED Consent form

Living with Lung Cancer Study

Informed Consent Form

The Centers for Disease Control and Prevention (CDC) and RTI International are interviewing 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 living with lung cancer, 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.

Each interview will last about an hour. It can be completed in one or two sessions, if needed. You may choose not to answer any question. You can stop the discussion at any time. Your choice to take part will not affect the health care you receive and you will still be compensated for your time.

Other study staff may listen to us talk so they can take notes. A staff member from the CDC, who is sponsoring this research, may listen in as well. We will also tape record the interview. The tapes help us get everything you have to say. Only study staff members will be able to listen to the tapes. The tapes will be destroyed after we write up our notes.

The project will not use your name on any written reports. Everything we learn will be kept private by project staff. The reports will put together what we learn from everyone in this study and will not use names.

There is no benefit to you for being part of this study. There could be future benefits to other individuals with lung cancer. Fifty dollars will be provided to you to cover any costs for participating in the interview. There should be no physical risks to you for participating. It is possible that some of the things we talk about could make you uneasy.

If you have questions about the interview, you can call or e-mail Jon Poehlman at 1‑800‑334‑8571 extension 27068, jpoehlman@rti.org. If you have any questions or concerns about your rights as a participant, you can call the Director of RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Name_________________________________ Date_______________________

reading grade level 7.9 assessed using flesch-kincaid

The following are some phone numbers and Web sites you can go for further information and support concerning lung cancer. We would also encourage you to contact your doctor if you have any personal questions about your cancer after having participated in the CDC interview.

Phone Assistance:

1-800-4-CANCER

Websites:

cdc.gov

cancer.gov

healthfinder.gov