Form CMS-10467 Consent Form for Key Informant Interviews and Focus Grou

Evaluation of the Graduate Nurse Education Demonstration Project

Consent Form for Key Informant Interviews and Focus Groups

Purpose
This evaluation is sponsored by the Centers for Medicaid & Medicare Services (CMS) and
conducted by Optimal Solutions Group and the American Institutes for Research (AIR). The
purpose of this research study is to evaluate the Graduate Nurse Education (GNE) demonstration,
identify the challenges and monitor its implementation, assess outcomes, and assess the potential
for sustainability, improvement and replication of key outcomes.
This interview is intended to gather information about challenges encountered and strategies
utilized to overcome them during the demonstration implementation and to gather information on
strategies that may potentially increase the number of Advanced Practice Registered Nurses
(APRNs).
Participation
Your participation in this interview is voluntary. If, at any time, you wish to discontinue
participation, you may do so without penalty.
Procedures
The interview will last 30 - 60 minutes1 and will be audio-taped for our records. Only
Optimal/AIR will have access to the tapes and that they will be destroyed upon the completion of
the evaluation.
Risks and Discomfort
There are no anticipated or known risks in participating in this study. As explained below in the
section on confidentiality, you should be aware that we will be submitting reports that may
identify organizations by name. Your identifying information will not be published.
Benefits
Your participation in the evaluation will contribute to an understanding of how to expand the
number of clinical training opportunities for APRN students, and ultimately the number of
practicing APRNs.
Confidentiality
We will treat the information you supply in a confidential manner. Only selected staff from the
evaluation team will have access to your actual interview responses. You will not be identified
by name in any report to the public or the funder, but we may refer to you by title, e.g., “Dean,
School of Nursing,” “Chief Nursing Officer.”

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NOTE: The amount of time will be a function of the interview topic area. The times to be inserted will be: GNE
STRATEGIC PLANNING AND OVERSIGHT TEAM: 60 minutes; SCHOOL OF NURSING
ADMINISTRATION: 60 minutes; CLINICAL FACULTY: 90 minutes; APRN STUDENTS: 90 minutes;
CLINICAL PLACEMENT COORDINATOR: 60 minutes; PRECEPTORS: 60 minutes; DIRECTOR OF
NURSING/CLINICAL DIRECTOR: 60 minutes; CHIEF FINANCIAL OFFICER/BUSINESS MANAGER: 30
minutes.

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As part of the evaluation, we will share our findings with CMS. The results of the evaluation will
describe strengths as well as areas for improvement. Findings will describe the progress made
and difficulties encountered in achieving project goals. Although you will not be identified by
name, it is likely that readers will be able to identify specific GNE projects and may also be able
to identify participating individuals based on their role within the project.
After the interview is completed, we will ask you to identify any information which you would
NOT want presented in any form that might be linked with your personally or with your GNE
project. We will comply with your request by being especially careful to not present such
information in any way that would enable it to be linked to you or your GNE demonstration
project.
More Information
For more information about this evaluation, please contact Julie Jacobson Vann at
jjacobsonvann@air.org or (919) 918-4503 or Brandy Farrar at bfarrar@air.org or (202) 403-5416.
For questions regarding your rights as a human subject participating in this research, please contact
AIR’s Institutional Review Board (IRB) Chair, at IRBChair@air.org; 800.634.0797.
Documented Consent
By signing this form you are indicating that you have read and understood the information
provided to you and agree to participate in the interview.

Name___________________________________ Organization___________________________
Signature ________________________________ Title _________________________________
Date ____________________________________

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