Consent

Attachment 5: CDSMP Evaluation Informed Consent

Chronic Disease Self-Management Program (CDSMP) Evaluation Consent Form

Dear CDSMP Participant,

The Centers for Disease Control and Prevention (CDC) are working on an evaluation of the Chronic Disease Self-Management workshops held in American Samoa, CNMI, FSM, Guam, Palau, and RMI.

This evaluation will help the CDC:

• Understand what participants liked and did not like about CDSMP workshops.

• Understand how the CDSMP workshop did or did not improve participants’ health and healthy habits.

Knowing this information will help the CDC make improvements to the CDSMP program so that future participants enjoy the workshops and improve their health and healthy habits.

You can CHOOSE to participate in some or all of the evaluation. If you choose to participate, you will complete:

• One survey on your satisfaction with the CDSMP workshop.

• One survey on your health and healthy habits before the CDSMP workshop.

• One survey on your health and healthy habits after the CDSMP workshop.

You can choose to take one survey, two surveys, or all three surveys. You can change your mind about participating at any time even after you have started a survey. If you CHOOSE to participate:

• CDSMP Leaders and CDC evaluation staff will be the only people who see the surveys.

• We will not share your information with anyone, including your name.

• CDC evaluation staff will put together all participant surveys answers. This will make sure no one knows what an individual person reported.

• The risk of filling out the surveys is the time it takes to fill it out, getting tired filling out the surveys, and feeling uncomfortable about taking a survey about your health.

• The benefit of filling out the surveys is helping improve the CDSMP workshop for future participants.

If YOU DO NOT want to participate in the evaluation, it DOES NOT AFFECT YOUR PARTICIPATION in the CDSMP workshop or access to any other health services you may have or may seek in the future. This evaluation is voluntary.

Thank you for your time and for considering being part of this evaluation.

Please sign below if you volunteer to participate in the CDSMP evaluation.

_____________________________________________ ___________________

Signature Date