Informed Consent

Informed Consent to Participate in a Focus Group

You have agreed to participate in a focus group about the Centers for Disease Control and Prevention’s (CDC) Field Triage Decision Scheme: The National Trauma Triage Protocol (Decision Scheme) and accompanying materials. CDC has contracted with NOVA Research Company (NOVA) to lead the focus group discussion about the Decision Scheme and prepare a report based on multiple focus group discussions. NOVA is an independent evaluator. A representative from CDC may listen in on the group discussion.

In the focus group you will be asked about your knowledge and implementation of the Decision Scheme and accompanying materials. You may choose not to answer a question or stop your participation in the group at any time without affecting your relationship with CDC. You will receive $50 for participating in the group.

Your focus group will be audio taped by NOVA. The audio tape, its transcript, and any other information collected during the focus group will be kept in a secure locked cabinet at NOVA, while electronic files will be kept on a physically and electronically secure NOVA server.

During our discussion we will only use first names. After our discussion, no personal identifying information will connect you to this project—your name and opinions will be kept private to the fullest extent permitted by law. Responses from all the focus groups will be put together in the final report and no names will be used; therefore, with the exception of those individuals participating in your focus group, no one will know who said what during the focus group.

Please ask the group leader any questions you might have about this project.

SIGNATURES

By signing below, you indicate that you have read this form, you agree to participate in the focus group about CDC’s Field Triage Decision Scheme, you agree to be audio-recorded, and you understand your rights as a research participant.

I consent to be audio-recorded during this focus group. (If you choose not to be audio‑recorded, you cannot participate in the group.)

[Circle response] Yes No

Please print your name: ____________________________________________

Please sign your name: ____________________________________________

Date: ___________________________

Informed Consent to Complete Online Survey

You have agreed to help us evaluate the Centers for Disease Control and Prevention’s (CDC) Field Triage Decision Scheme: The National Trauma Triage Protocol (Decision Scheme) and accompanying materials by completing this online survey. This survey will ask you about your knowledge and implementation of the Decision Scheme and accompanying materials.

Your personal information will be kept private to the fullest extent permitted by law. Your answers will be stored separate from your identifying information in a secure environment. During analysis, survey answers will be combined across all respondents and reported in the aggregate. CDC will not be informed of your personal responses to survey questions. Your participation in this survey is voluntary.

If you have any questions about the survey, please contact Dan Eckstein:

DEckstein@novaresearch.com

NOVA Research Company

4600 East-West Highway, Suite 700

Bethesda, MD

(301) 986-1891

 By checking this box, you indicate that you have read this form, you agree to participate in this survey about CDC’s Field Triage Decision Scheme, and you understand your rights as a research participant.