0990- ONC Survey Introduction and Consent Script

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Introduction and Consent Script

This is __________ calling on behalf of the U.S. Department of Health and Human Services. We are conducting an important research study to learn more about what people think about the privacy and security aspects of electronic health records and electronic health information exchange and the ways that they may affect how you manage your health information. Your telephone number/cell phone number has been selected at random.

[FOR LANDLINE SAMPLE ONLY:] I would like to speak to a member of the household who is age 18 or older who will have the next birthday. Would that be you? [IF YES, CONTINUE; IF NO, ASK TO SPEAK WITH THAT PERSON. ONCE CORRECT PERSON IS ON PHONE, CONTINUE.]

[FOR CELL PHONE SAMPLE ONLY:] Are you at least 18 years of age? [IF YES, CONTINUE.]

The interview will take approximately 25 minutes. Your participation is voluntary, but important. If we come to a question you don’t want to answer, we will skip over it. You can end the interview at any time. The information you provide will be kept private to the extent allowed by law. You will not be identified in any report of these interviews.  I also want to let you know that this call may be monitored or recorded for quality purposes. Do you have any questions about the study?

[INTERVIEWER, READ IF NECESSARY: NORC at the University of Chicago is the research organization coordinating this research. If you have any questions about the study, you can call the NORC IRB Administrator toll-free at 866-309-0542.  If you have any questions about your rights as a study participant, you can call Penelope Hughes of the Office of the National Coordinator for Health Information Technology at 202-205-8568.]

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer