National CLAS Standards Evaluation Informed Consent Form – Interview
FORM APPROVED
OMB No: 0990-XXXX
Expires: MM/DD/YYYY
PURPOSE
The
Office of Minority Health (OMH) at the Department of Health and Human
Services (HHS) is working to understand how its National
Standards for Culturally and Linguistically Appropriate Services in
Health and Health Care,
or the National
CLAS Standards,
National
CLAS Standards,
are understood, adopted, and implemented in health and health care
organizations across the country. As part of this evaluation project,
we are conducting key informant interviews with health and health
care professionals throughout the country. The key informant
interview will take approximately 60-90 minutes.
RISKS
There
are no foreseeable risks for participating in this research.
BENEFITS
While
there are no direct benefits to you, by taking part in this project,
you have the opportunity to help the HHS Office of Minority Health
better understand how health and health care professionals and
organizations become aware of, gain knowledge about, adopt, and
implement the National
CLAS Standards.
CONFIDENTIALITY
The
data in this study will be confidential.
Everything
you tell us will remain anonymous. We will not use your name or other
identifying information in any materials that result from this
project.
To ensure that all information is accurately captured, the interviews will be audiotaped and transcribed. Recordings will be kept secure and password-protected in a locked file in the principal investigator’s office and will be destroyed after seven (7) years. I give permission to have my interview audio-recorded.
Yes No _________Initials ____________Date
PARTICIPATION
Your
participation is voluntary, and you may withdraw from the evaluation
project at any time and for any reason. If you decide not to
participate or if you withdraw from the project, there is no penalty
or loss of benefits to which you are otherwise entitled. There are no
costs to you or any other party.
CONTACT
This
evaluation project is being conducted by the Health Determinants &
Disparities Practice at SRA International, Inc. and Rodney Hopson,
College of Education and Human Development, Division of Educational
Psychology, Research Methods, and Education Policy at George Mason
University. Staff in the Health Determinants & Disparities
Practice at SRA International may be reached at 240-514-2991 for
questions or to report an evaluation-project related problem. You may
contact the George Mason University Office of Research Integrity and
Assurance at 703-993-4121 if you have questions or comments regarding
your rights as a participant in this project.
This
research has been reviewed according to George Mason University
procedures governing your participation in this research.
CONSENT
I
have read and understand the information regarding my participation
in this interview about the HHS OMH’s National
CLAS Standards,
all of my questions have been answered by the research staff, and I
agree to participate in this study.
__________________________
Name
__________________________
Date
of Signature
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Barksdale, Crystal |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |