CMS-10549.GenIC#3 - Att. D Consent Form

PARTICIPANT NUMERIC IDENTIFIER: ___________________________

The Centers for Medicare & Medicaid Services (CMS) is a federal agency that is part of the United States Department of Health and Human Services. CMS administers the Medicare program and conducts the Medicare Current Beneficiary Survey (MCBS), a national survey of Medicare beneficiaries in the United States. To assure that the MCBS obtains the best information possible, CMS sometimes conducts evaluations of the MCBS questionnaire.

You have volunteered to take part in a study to improve the MCBS. The MCBS asks Medicare beneficiaries about their health status, sources of health care, satisfaction with care, and health care expenditures. In today’s interview I will be asking you about your chronic conditions. After we have finished the survey, I would like to talk with you about how you interpreted the questions and came up with your answers. Getting your feedback on the questions will help make the questions better. This interview will take about one hour.

In order to have a complete record of your comments, with your permission, your interview session will be audio taped. The recording will be stored electronically on NORC’s secure servers. We plan to use the recording to ensure that we capture all of the feedback you provide us. Only staff at NORC and HHS/CMS directly involved in this research project will have access to the recording. Any quotes used in presentations and publications will not include any names or any information that could identify any participant.

Your participation in this interview is voluntary. You may skip questions or end the interview at any time and you will still receive the $40 payment. All survey information will be kept strictly confidential. Your Medicare benefits will not be affected in any way by your decision whether to participate.

For questions regarding research subjects’ rights, please contact the NORC IRB Administrator, toll-free at 866-309-0542.

□ I have volunteered to participate in this study, and I give permission for my audio recording to be used for the purposes stated above.

□ I have volunteered to participate in this study, but I do not want my interview to be recorded.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1275 (expires 05/31/2021). The time required to complete this information collection is estimated to average 70 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact MCBS@cms.hhs.gov.