CMS-10816 Informed Consent

Attachment D: Informed Consent Form
Introduction
Thank you for taking the time to participate in today’s interview. My name is __________ and I
work for NORC at the University of Chicago, an independent research organization.
You have volunteered to take part in a study to improve the Centers for Medicare and Medicaid
Services or CMS Medicare Advantage (also referred to as Part C) and Prescription Drug Plan
(also referred to as Part D) enrollment form. During this interview, I will ask you several
questions to understand the how you filled out the Medicare enrollment form. Before we get
started, I would like to share some information with you about what you can expect:
• First, this interview will take about 45 minutes.
• Second, your participation is completely voluntary. You may decline to answer any
questions you wish and you are free to end the discussion at any time. There will be no
consequences for ending the interview early. Your Medicare benefits will not be affected
in any way by your decision whether to participate. The OMB control number for this
study is OMB No.____, expiration _____.
• The information you provide is confidential, consistent with the Privacy Act of 1974 and
you will not be identified in any reports or written documents. As in any study, there is a
small risk of possible loss of privacy, but NORC is committed to keeping your personal
information private. We will keep the information from this interview on NORC’s secure
servers and only accessible to those on this project team. At the end of the project, NORC
will share a summary of results to CMS. In this report, your name will not be listed or
associated with any quotes.
• I will be taking some notes, and with your permission, I would like to record the
discussion for notetaking purposes only. The notes and recording will be destroyed at the
completion of this study.
• At the completion of this interview, you will receive a $75 gift card for your time.
• If questions arise following this interview, you may contact the Project Director, Susan
Cahn, at (312) 357-7035 or cahn-susan@norc.org. If you have questions about your
rights as a project participant, you may also call the NORC Institutional Review Board
Manager at (866) 309-0542.
Do you have any questions before we begin?
Do you consent to participate in this study?
Do I have your consent to record this discussion?