Consent Form

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

All Age Influenza Hospitalization Surveillance (Flu Hosp) Project

Consent Form

Consent Form (for patient/proxy interview ONLY)

Influenza Hospitalization Surveillance Project

VERBAL CONSENT FORM

Hello. My name is __________ from the _____[state] Department of Public Health. May I speak to ______ [patient’s name /parent of [child’s name] ] . We are working with the Centers for Disease Control and Prevention and other health departments to learn more about influenza disease or the flu. To do this, we are talking to people who have been in the hospital with the flu. We want to look at things that may affect their illness and whether they were vaccinated against the flu.

Because you/your child [or NAME if speaking with proxy] were in the hospital for the flu beginning on _______[day admitted], I would like to ask you a few questions about whether you/your child [or NAME if speaking with proxy] received the flu vaccine this season. This will take about five minutes. Your participation is voluntary and if you choose to refuse it will not affect any medical care or benefits you receive. All of your responses will be kept confidential as much as the law allows. You may refuse to answer any questions and may stop at any time. This information will help [State/Local Health Department] and CDC better describe influenza-associated hospitalizations. Additionally, this information may help us improve vaccination recommendations for flu and better protect the public’s health. There is no other benefit to you for answering these questions. There is also no risk to you. If you have any questions about the study, you may call _____[state contact] at the Department of Public Health at XXX-XXX-XXXX. Do you have any questions before I begin?

May I continue with this interview? □ Yes □ No

If YES, go to Appendix D.

If NO: Thank you for your time. Have a good day.

Name of person obtaining verbal consent: _______________________________

Date: _______________________________

Flesch-Kincaid: 7.7

Case and Proxy Identifying Information

Influenza Hospitalization Surveillance Project

Patient’s:

Last name________________ First name____________ Initial__

Date of birth: ____/____/______

Phone_____________

Proxy’s:

Last name________________First name____________ Initial__

Phone_________________

Relationship to case patient _________________________

Note to collaborators: This is for your records only. Do not send this information to CDC. Keep this information in a secure locked place.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).