Consent

Attachment 7D

Informed Consent Form

Informed Consent

CRCCP Impact Evaluation Informed Consent Form

Thank you for agreeing to speak with me today. ICF Macro, on behalf of the Centers for Disease Control and Prevention (CDC), is conducting a case study to better understand the impact of the CDC’s Colorectal Cancer Control Program.

We are conducting this interview with you because you have been identified as a person who can describe details about the management, design, and implementation of your program. Your opinions and thoughts are extremely valuable to our project, and there are no right or wrong answers. This interview is not meant to evaluate you; rather it is meant to learn insights from you about how your program is managed and operates.

Participation will take approximately 60 minutes of your time. We are planning to interview 10-12 individuals familiar with your program. There are no known risks and no direct benefits from participating in this interview.

Information obtained through this interview will help CDC understand how their program may affect colorectal cancer screening. As the interviewer, with your permission, I will audio record our conversation; an additional member of the ICF Macro study team will take notes of our discussion. We will NOT link your name or your role/title to specific responses in any reports developed from this study, and your identity and your answers to any questions that I ask you during this interview will be treated in a secure manner. We will use the information we learn from this interview to supplement our site visit summary. This summary will be shared with the project team members (ICF Macro staff and CDC staff) as well as the Program Director so that it can be reviewed it for accuracy.

Your participation is completely voluntary. You may choose not to answer some of the questions or you may choose not to participate without penalty. You can choose to discontinue the interview at any time for any reason.

If you have questions about your rights as a participant, you may contact the Project Director, Michelle Revels at 404-592-2156.

Before we begin with the discussion, I would like to get verbal consent to proceed. Do you agree to participate in this interview?

• Yes  Thank you. I confirm that you are willing to answer the questions in this discussion and will note your verbal consent. We would also like to record the conversation to make sure we don’t miss anything.

• No  Thank participant for his or her time and end conversation.

Do I have your permission to turn on the audio recorder?

• Yes  Thank you. Turn on recorder.

• No  Thank you. I will refrain from recording the session.

Do you have any questions for me before we begin?

Pause for participant response(s).