Attach C-1_Consent Form English

ATTACHMENT C-1: CONSENT FORM, ENGLISH

We would like to talk with you about a questionnaire Westat is developing as part of the Health Information National Trends Survey (HINTS). Westat is conducting this research for the U.S. Dept. of Health and Human Services (HHS). The questionnaire asks about health-related topics. By taking part in this interview, you are helping us evaluate how easy or difficult the questions are to understand and answer. Your opinions will help us improve the questionnaire.

• Your participation is completely voluntary. You may stop at any time, and you can skip any questions you do not wish to answer.

• All information obtained during this study will be treated as secure and will only be used to develop and improve the questionnaire. We will not share your answers with anyone outside of the HINTS project research team.

• The interviewer will audio record the discussion and take notes. In addition, project researchers may observe the interview. The researchers will destroy the audio recording as soon as they complete the questionnaire development process.

• The interview should take about an hour and a half.

• The report summarizing the findings will not contain any names or identifying information.

• You will receive $50 cash as a token of our appreciation for completing the session.

• If you have questions about this research, please contact Brad Hesse, the Principal Investigator at (301-594-9904; hesseb@mail.nih.gov). If you have questions about your role as a research participant, please contact Sharon Zack, the Westat Institutional Review Board Administrator (301-251-1500; sharonzack@westat.com).

• A copy of this consent form has been provided for your records.

If you agree to participate in this interview, please sign the following statement.

I have read this consent form and understand the proposed project. I consent to participate in this study and to have the interview audio taped.

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Participant’s Signature Researcher’s Signature

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Printed Name Printed Name

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