Web-based Survey Informed Consent

Form Approved

OMB Control No. 0920-1193

Exp. Date XX/XX/202X

Attachment 5f.

Web-based survey Informed Consent

Web-based Survey Informed Consent

Thank you for participating in the survey!

The Centers for Disease Control and Prevention’s (CDC) Division of Cancer Prevention and Control (DCPC) funds the National Comprehensive Cancer Control Program (NCCCP). Through a cooperate agreement (DP18--1805), 2 organizations have been funded to provide training and technical assistance (TTA) to NCCCP awardees and partners, in order to increase NCCCP awardees and partners’ capacity to implement cancer control activities to comprehensively address all cancer types. DCPC is interested in assessing the reach, quality, and effectiveness of TTA provided by these 2 organizations. This survey is being administered to program directors and program managers of state-funded NCCCP awardees and other individuals involved with these programs (e.g., Comprehensive Cancer Control coalition members, partners). Your response to the survey will help CDC understand the reach of the TTA efforts, your experience with the TTA received, and your perceptions of the effectiveness of the TTA.

This survey is being administered by ICF, an independent consulting company, on behalf of CDC.

Please respond to the questions according to your individual experience. We expect this survey to take approximately 15 minutes to complete, depending on the number of providers you received TTA from. Your responses to this survey will be kept private and stored and maintained by ICF, without any identifying information. Individually identifiable responses will not be provided to CDC staff, and only aggregated information will be reported. We are not aware of any risks associated with participating in this survey. Completion of this survey is voluntary. Choosing to not participate, or choosing to discontinue the survey will not result in any penalty. We encourage your participation, as your organization’s experiences will help inform CDC’s future efforts to build capacity among their funded programs. Completing this web-based survey will indicate your consent to participate.

If you have any questions about this survey, please contact Isabela Lucas, at 404-434-3154 or email at Isabela.lucas@icf.com.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA 0920­1193.

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