bf Adult Consent Form

Tab H: Consent Form for Adult Woman Assessment Form

BRIGHT FUTURES FOR WOMEN’S HEALTH AND WELLNESS

ADULT WOMAN CONSENT FORM

This health center is participating in a multi-site research project being run by Health Systems Research, Inc. under contract with a Federal Government Office of Women’s Health. This clinic is helping to assess whether the Bright Futures physical activity and healthy eating materials were helpful to you. 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 be in this one-time assessment, it will take about 25 minutes to fill out this form. You will not put your name on the form. If you decide to fill out the form, 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 change the health care you get at this center, now or in the future.

You may not gain anything from filling out this form. By giving feedback on the Bright Futures materials, you will help this center and others decide whether to use the 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.

__________________________________ ________________________

Patient Signature/Date Consent Administrator

Not Valid Without IRB Approval Stamp on Last Page