Consent

ATTACHMENT e5

site visit consent form

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Consent form for WISEWOMAN KEY INFORMANT interviews

Introduction/Purpose

The Centers for Disease Control and Prevention (CDC) is conducting an evaluation of the

Well-Integrated Screening and Evaluation for the Women Access the Nation (WISEWOMAN) program. You are invited to participate in a key informant interview that is being conducted as part of the evaluation. Results from this evaluation are intended to inform policymakers about how different sites have implemented the WISEWOMAN program, how well the WISEWOMAN program is working, and how it can be improved. You were selected as a key informant because of your role as a WISEWOMAN program administrator, health care provider, or community partner. Your participation will provide an important perspective on the WISEWOMAN program. Before you decide to be a part of this study, you need to understand the risks and benefits associated with your participation.

Procedure

You are being asked to participate in a key informant interview with a member of the study team. You will be asked about your experiences with the WISEWOMAN program. During the interview, we will take notes and audio record the interview, if you give your permission for that.

There are no “right” or “wrong” answers; we are only interested in learning about your experiences and opinions. Your answers will not have any impact on the funding or any other support that your organization may receive. You may choose not to answer any questions that we ask and you may terminate the interview at any time. The interview should take about [75 minutes (for administrators)/ 45 minutes (for service staff and providers)] to complete.

Benefits

While you will not benefit directly from this study, your comments will inform policymakers about how the WISEWOMAN program helps improve the cardiovascular health of un- and under-insured women.

Risks

There is no known risk to you for participating in the interview. Although we have made every effort to reduce any risk to you by participating in this interview, and to make sure everything is private, you may decide not to answer any questions that make you feel uncomfortable in any way.

Confidentiality

To protect your privacy, we will keep private all information you give us as we develop our notes and evaluation reports. We will not identify you personally in any report or publication of this study. Recordings from the interview will be stored in a project password protected folder that can only be accessed by the study’s research team. The interview transcriptions and summaries will be locked in a cabinet in the project office. While project records can be opened by court order or produced in response to a subpoena or a request for production of documents, we will keep any records that we produce private to the full extent of the law. All documents and interview recordings will be destroyed at the end of the project.

Participation Is Voluntary

Your participation in the interview is entirely voluntary. You may withdraw your consent or stop taking part at any time, without penalty. You may refuse to answer any question you do not wish to answer during the interview.

Questions

If you have any questions about the taking part in the interview you can contact So O’Neill at Mathematica ((617) 301-8975). If you have questions about your rights as a participant, you can contact Kate Marchand at our Institutional Review Board (617-243-3924 or kate.marchand@neirb.com).

If you agree to participate and to be audio-recorded, please read this statement aloud so we can record it.

I, [NAME] of [ORGANIZATION], understand the purpose of the interview I am being asked to do and I agree to be interviewed as a key informant in the WISEOWOMAN evaluation.