Attachment D2_Consent Form_Nov 12 2012

Telephone interviews with State CHIP program administratorS

PARTICIPANT INFORMED CONSENT

Study Title: CHIPRA-Mandated Evaluation of the Children’s Health Insurance Program

Principal Investigator: Mary Harrington, Mathematica Policy Research

Sponsor’s Name: U.S. Department of Health and Human Services

Introduction/Purpose

You are invited to participate in an evaluation of the Children’s Health Insurance Program’s (CHIP) required by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). The study is funded by the U.S. Department of Health and Human Services. Results from the evaluation are intended to inform policymakers on the nature and magnitude of change CHIP programs have experienced in the past ten years, the influence of key design features on the enrollment and health care experiences of eligible children, and current program and policy issues. In addition, the evaluation will assess major aspects of CHIP and provide an opportunity to see how 10 selected State programs compare with one another to gain insights on important factors influencing program operations and outcomes. An important component of this evaluation will include telephone interviews with CHIP program administrators in all 50 States and the District of Columbia.

Procedure

You are being asked to participate in a telephone discussion that will last approximately one hour. During the discussion, we will cover a range of issues, including the influence of CHIPRA on your State’s CHIP program, Affordable Care Act preparations, how CHIP is being coordinated with other insurance affordability programs, financing and budget concerns, and future plans for your CHIP program. Two Mathematica researchers will be taking written notes of your answers. The interview will be audio recorded with your permission.

Confidentiality

To protect your privacy, you will not be personally identified in any report or publication without your prior permission. Similarly, none of your remarks will be quoted in our reports without your permission. We typically do not quote anything a key informant tells us during an interview in our reports, nor do we identify who says what. If the situation arises where we would like to quote something that you tell us, we will ask your permission before doing so. If you prefer not to be quoted, we will respect your wishes. Recordings from each interview will be stored in a secure password-protected folder that can only be accessed by the study's research team. The interview notes/summaries will be locked in a file folder in a locked project office. We will keep any records that we produce secure to the extent we permitted by law. Records can be opened by court order or produced in response to a subpoena or a request for production of documents. The records will be destroyed after the completion of the project by deleting them from the password protected project folder on the evaluation team’s research network. All documents created from the interview will be shredded after the end of the project.

Participation is Voluntary

Please understand that your participation in this discussion is entirely voluntary. You have the right to withdraw your consent or stop your participation at any time without penalty. You also have the right to refuse to answer any questions during the discussion. Your participation will remain completely anonymous. The researchers involved in the study will protect the confidentiality of your responses to the extent permitted by law, even if you make negative statements, or otherwise complain about the CHIP program or the government agencies overseeing.

Questions

If you have any questions about this discussion, including any questions that concern your rights as a participant on the project, you can contact Mary Harrington at 734-794-1124. Mathematica uses the New England Institutional Review Board as their Institutional Review Board. You may call Katie Goldberg at 617-243-3924 if you have questions about your rights as a participant in this study. This Review Board oversees the protection of human research participants. You will receive a copy of this consent form for your records.

Agreement Statement

Do you agree to participate in the Department of Health and Human Services CHIPRA 10-State Evaluation of the Children’s Health Insurance Program?

Yes ____ No ____

Do you agree to have this interview recorded?

Yes ____ No ____

Date of Consent: ___________________

Name of Interviewer (print): __________________________________________

Signature of Participant: _____________________________________________

(E-Signature will be accepted as this document can be sent via e-mail.)