ATTACHMENT 4b
Provider Survey:
Consent Statement, English
You are being asked to participate in this survey because you are a provider at [NAME OF CLINIC]. The purpose of this survey is to gather information about your attitudes toward prostate cancer screening and current practices.
Who is sending this survey? ICF is a consulting firm that is working with the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC).
How long will the survey take? This survey will take no longer than 10 minutes. Your participation in this study is 100% voluntary which means you can choose whether you want to complete this survey.
What are the risks and benefits of doing the survey? As a respondent to this survey, there is a minimal risk related to your privacy and/or confidentiality, but steps have been taken to remove your personal information so that you cannot be identified. Only members of the survey team will have access to this information. Remember, your participation is completely voluntary.
How will my information be shared outside of the study? Your personal responses will not be shared outside of the study. Summaries of survey results that are not linked to your name or clinic will be shared with CDC and/or may be published in a professional journal.
Who do I call about problems or questions? If you have questions about or concerns about your participation in this project, please contact the ICF project manager - Danielle Nielsen at Danielle.Nielsen@icf.com. For questions regarding your rights as a study participant, you can contact ICF’s Institutional Review Board (IRB) representative Christine Walrath at (646) 695-8154 or Christine.Walrath@icf.com. Further, you may contact the CDC point of contact, [NAME] for more information about this study and how CDC may use the results.
If you agree to participate in this study, please click “Begin Survey.”
If you do not agree to participate, please click, “I decline.”
☐ Begin survey (Go to Q1)
☐ I decline (Go to Termination page)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jenn Mezzo |
| File Modified | 0000-00-00 |
| File Created | 2024-09-05 |