Consent

Attachment C – Consent Form

[COMPANY NAME] is collaborating with Brown University School of Public Health regarding antimicrobial stewardship in long-term care settings. This survey will ask you questions regarding your knowledge, attitudes, practices and perceived provider-level barriers to appropriate antibiotic prescribing as it pertains to your role as a prescriber. This information will be used to identify ways to improve prescribing practices and to better understand the current prescribing environment. Your participation is voluntary and all responses will collected by and only visible to researchers at Brown University. Any reporting will be done in aggregate (your identity will not be linked to your response).

If you choose to participate, you may skip any question you are not comfortable with or exit/discontinue the survey at any point.

If you decide not to participate, or if you decide to end the survey at any point, there will be no penalty or loss of benefits to which you are otherwise entitled.

We expect this survey to last less than 30 minutes. You will not benefit directly from taking part in this research study.

Please reach out to _ [staff at Brown] _ with any questions regarding the project.

By choosing to continue, you are indicating that you understand the above and agree to participate:

[continue] – (continue to survey)

[end] – (survey ends with message: Thank you for your consideration.)