bf Provider Consent Form

Tab I: Consent Form for Health Care Provider Assessment Form

BRIGHT FUTURES FOR WOMEN’S HEALTH AND WELLNESS

HEALTH CARE PROVIDER CONSENT FORM

This health center is participating in a multi-site research project being run by Health Systems Research, Inc. under contract with the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Office of Women’s Health (HRSA OWH). The research project will explore whether the Bright Futures materials were helpful to you in having a clinical conversation with your women patients and setting physical activity and healthy eating goals with them.

This research project is being conducted at six locations across the United States and approximately 2,400 young and adult women will take part. The research project is designed to examine how well the materials work.

If you agree to take part in this one-time assessment, it will require you to fill out the attached assessment form. This will take approximately 20 minutes. You will not put your name on the form and you can stop at any time. If you decide not to fill out the form or only fill out some parts of it, it will not impact your employment at this health care center.

You may not gain anything from filling out this form. By giving feedback on the Bright Futures materials, you will help your clinic and the HRSA OWH make critical decisions about the distribution and support of these materials.

This assessment does not pose any risks to you. All of the information you put on the form will be kept private. It will be stored in a locked file cabinet at the Health Systems Research Inc. offices in Washington, D.C. There will be no way to link you to your answers.

If you have questions about this assessment please call Ms. Rebecca Ledsky at Health Systems Research, Inc., at (202) 776-5136. If you have question about your rights in this assessment call the National Center for Health Statistics Institutional Review Board Chair at (301) XXX-XXXX.

I agree to take part in this assessment.

__________________________________ ________________________

Health Care Provider Signature/Date Consent Administrator

Not Valid Without IRB Approval Stamp on Last Page