Attachment O -- ED Provider Paper Statement of Informed Consent

The Study of the Use of Nursing Home Antibiograms

Emergency Department Provider Statement of Informed Consent – Paper and Pencil

Abt Associates Inc. and our partner Brigham and Women’s Hospital (BWH) have been hired by the Agency for Healthcare Research and Quality (AHRQ) to develop a program to improve antibiotic prescribing practices for residents of nursing homes (NHs) and for NH residents who are transferred to the emergency department (ED). You are being asked to participate in this survey because you are a physician at the BWH ED.

We will be asking questions related to your antibiotic prescribing practices. All data gathered through the provider surveys will be aggregated; no direct quotes will be attributed to individual respondents. Responses will be summarized and reported across all BWH providers who participated in the survey (i.e., three at pre-implementation; approximately 50 at post-implementation). The BWH may be named in reports to AHRQ and may be named in publications or presentations that may result from this work. Your participation in the survey is voluntary and you may refuse to answer any question. No penalty or loss to you or to the patients you treat will result from refusal to participate or from survey discontinuation at any time. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). We expect this survey to take approximately fifteen to twenty minutes to complete.

If you have any questions about this survey or the project itself, you may contact the project director at Abt Associates Inc., Rosanna Bertrand, at (617) 349-2556. For questions about your rights as a participant in this study, please call Teresa Doksum, Abt Associates Institutional Review Board Administrator, at (617) 349-2896 (a toll call).

Your signature below indicates that you are agreeing to the terms stated in this informed consent.

Signature

Date

Abt Associates Inc.