Consent Form

Attachment 2: Consent form

Informed Consent Form

Project title	Formative assessment to inform the redesign of the Research Tested Intervention Programs (RTIPS) website
Statement of Age of Subject	I state that I am at least 18 years of age, in good physical health, and wish to participate in a program of research being conducted by xx in the Division of Cancer Control and Population Sciences of the National Cancer Institute, Bethesda, MD 20892.
Purpose	The purpose of this research is to understand how public health and or cancer control practitioners make decisions to adopt and implement evidence-based programs for use in their practice settings. These data will inform the redesign and development of the Research Tested Intervention Programs (RTIPs) website for maximum utility and use.
Procedures	Participants will be asked to answer questions and give feedback during the interview. The total time involved, including instructions, will be no more than 30 minutes.
Confidentiality	All information collected in this study is confidential. I understand that the data I provide will be grouped with data others provide and that my name will not be used. I understand that the telephone interview will be recorded but will not be shown to others besides the research team without my written permission.
Risks	I understand that the risks of my participation are expected to be minimal in nature. We won’t ask for any personal information that would have financial or legal implications. Results will be reported only in aggregate form, and no identifying information will be shared.
Benefits, Freedom to Withdraw, & Ability to Ask Questions	I understand that this study is not designed to help me personally but that the investigators hope to improve the website. I am free to ask questions or withdraw from participation at any time without penalty.
Contact Information of Investigator Please Return Signed Form to	Name: XXX Position: XXX Telephone: XXX Email: XXX Name: [contractor] Email: XXX

Printed Name of Research Participant __________________________

Signature of Research Participant ____________________________

Date______________