OMB XXX-XXXX
FOCUS GROUPS WITH PATIENT NAVIGATORS
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Consent for Participation and Session Recording
I, ______________________________________________________________,
(Print your name here)
consent to the audio recording of this focus group session, which is being conducted by NOVA Research Company to help the Health Resources and Services Administration (HRSA) study ways it can help patients to overcome barriers and gain greater access to health care through the Patient Navigator Demonstration Program (PNDP).
I acknowledge that my participation in this session is voluntary. I understand that the recording will be used only by the research staff to accurately capture the views expressed during the focus group, and that my name will not appear in the summary report.
I am aware that my participation in this focus group session will have no effect on my personal employment status, that identifying information about me will not be shared with HRSA, and that all of the information I share today is protected under the Privacy Act.
____________________________________________________
Participant’s Signature/Date
The Paperwork Reduction Act requires that HRSA display an OMB control number on all public information requests. The OMB Control Number for this study is XXX-XXXX. Also, if you have any comments regarding the time estimates associated with this study or suggestions on making this process simpler, please write to XXXX.
| File Type | application/msword |
| Author | Debra Stark |
| Last Modified By | HRSA |
| File Modified | 2011-06-14 |
| File Created | 2011-06-14 |