PARTICIPANT AGREEMENT Attachment A.pdf

PARTICIPANT AGREEMENT

We appreciate your interest in participating in one or more of upcoming studies by the Veterans Health

Administration (VHA) Human Factors Engineering office. The purpose of these studies is to improve the services offered to Veterans by gathering their feedback on health care tools, such as mobile apps or websites. Please review the following information, and if you agree to participate, follow the instructions for signing and returning this form.

Information about the studies:

• [HOW WILL I BE SELECTED FOR A STUDY?] You will be invited to join based on your answers to a screening questionnaire. If you agree to participate, you will receive a link to a website where you can provide your answers.

• [WHAT INFORMATION WILL YOU COLLECT?] The screening questionnaire will ask basic demographic information and about your use of technology. Some studies require participants with special characteristics such as a particular medical condition. When such studies occur, the study coordinators may ask all potential participants whether they have such characteristics, and if so, to respond according to the instructions they will provide.

• [WHEN DO STUDIES TAKE PLACE?] Studies can occur between 8:00 a.m. and 6:00 p.m.

Eastern time (or adjusted to the time zone where you live), Monday-Friday, excluding federal holidays. You will be contacted in advance with potential dates and times. Most of the studies will require one hour or less of your time.

• [DO I HAVE TO PARTICIPATE?] It is up to you whether or not to join a study. If you decide not to join, it will not change the benefits or care that you receive from VA. You never have to answer questions that make you uncomfortable. You can quit at any time.

• [WHAT WILL I BE ASKED TO DO?] Studies typically examine an upcoming piece of software that is being developed for use by Veterans like yourself. They typically involve asking you questions over the telephone and using the Internet to get feedback on a software product

VHA is developing. You will be compensated for your time. Some studies may also be conducted in person in your region. If you are selected to participate in these studies, you will be compensated for your travel to the study location.

• [WHAT CAN YOU TELL ME ABOUT THE STUDY?] When you are contacted, a short description of the study will be provided. If you agree to participate, you will be provided an information sheet. This will contain all details about the study, along with a contact name and number.

[WILL MY INFORMATION BE KEPT PRIVATE?] Your personal information and your answers are completely private. You will never be identified in any reports nor will anyone access your medical records or look at personal data during the sessions.

As a potential participant in a VHA Human Factors Engineering study, we ask that you agree:

• To keep your contact information up-to-date (e.g., phone number, e-mail address, postal address information)

• To allow your name to be kept on file for potential participation in future studies sponsored by

VHA

• To have your voice, computer screen, and (in the case of in-person studies), hands recorded if the study requires it. Your face will never be recorded. (Note: In these situations, participants will be provided with a separate A/V release form (VA Form 10-3203.)

• To maintain access to an Internet-connected computer and telephone that you are permitted to use for such studies

• That you are able to understand and speak English

If you agree with these conditions and want to be included as a potential participant in future studies, please sign the following page and return using one of the following methods:

• Print the form, print, and sign your name, print the date. Send the paper form to:

o [CONTRACTOR] o [CONTRACTOR ADDRESS] o [CONTRACTOR STATE, ZIP CODE]

• Print the form, print, and sign your name, and print the date. Scan the form, and send to:

o [CONTRACTOR EMAIL]

• Type your name and date, insert your signature (e.g., using an image file). Attach the form to an e-mail, and send to:

o [CONTRACTOR EMAIL]

Please keep pages 1 and 2 for your records.

Once we receive the form, you will receive confirmation via e-mail that you are included in the database of potential study participants.

PARTICIPANT AGREEMENT SIGNATURE PAGE

Please provide your name, signature, and date below to state your interest in participating in VHA HFE studies.

As a potential participant in a VHA Human Factors Engineering study, I agree:

• To keep my contact information up-to-date (e.g., phone number, e-mail address, postal address information)

• To allow my name to be kept on file for potential participation in future studies sponsored by VHA

• To have my voice, computer screen, and (in the case of in-person studies) hands recorded if the study requires it. My face will never be recorded. (Note: In these situations, participants will be provided with a separate A/V release form (VA Form 10-3203.)

• To maintain access to an Internet-connected computer and telephone that I am permitted to use for such studies

• That I am able to understand and speak English

Name Signature

Date